Provider Demographics
NPI:1942853627
Name:TUCKER, CHRISTOPHER RYAN (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:RYAN
Last Name:TUCKER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:CHRIS
Other - Middle Name:
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9808 VENICE BLVD PH
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-2732
Mailing Address - Country:US
Mailing Address - Phone:310-963-0365
Mailing Address - Fax:310-496-3101
Practice Address - Street 1:9808 VENICE BLVD PH
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2732
Practice Address - Country:US
Practice Address - Phone:310-963-0365
Practice Address - Fax:310-496-3101
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA57033363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant