Provider Demographics
NPI:1972521466
Name:TUCKER, VICKI J (CRNA)
Entity Type:Individual
Prefix:MS
First Name:VICKI
Middle Name:J
Last Name:TUCKER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12417 BELLA AMORE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76126-4952
Mailing Address - Country:US
Mailing Address - Phone:985-373-6525
Mailing Address - Fax:
Practice Address - Street 1:6317 HARRIS PKWY STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4267
Practice Address - Country:US
Practice Address - Phone:817-423-2888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN098755367500000X
TXRN604098367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX319503YNWNOtherMEDICARE GROUP MEMBER PTAN
MS00125846Medicaid
TX3276487-01Medicaid
LA1126535Medicaid
LA4C2837061Medicare PIN