Provider Demographics
NPI:1972862779
Name:RUCKER, MICHAEL P (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:RUCKER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2828
Mailing Address - Country:US
Mailing Address - Phone:719-543-7877
Mailing Address - Fax:719-543-7882
Practice Address - Street 1:1218 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2828
Practice Address - Country:US
Practice Address - Phone:719-543-7877
Practice Address - Fax:719-543-7882
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARRN#R79369163W00000X
ARCRNA#CTP-00203367500000X
COAPN.0991504367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse