Provider Demographics
NPI:1255162905
Name:TUCKER, ANTHONY JOSEPH (PA-C)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JOSEPH
Last Name:TUCKER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18261 EVERSON MILES CIR
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33917-3980
Mailing Address - Country:US
Mailing Address - Phone:734-904-9719
Mailing Address - Fax:
Practice Address - Street 1:2111 GLENWOOD DR STE 205
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3328
Practice Address - Country:US
Practice Address - Phone:800-531-1587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9119206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant