Provider Demographics
NPI:1295749349
Name:TUCKER, PATRICK EDWIN (MD)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:EDWIN
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 GETWELL RD
Mailing Address - Street 2:STE 1
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-6762
Mailing Address - Country:US
Mailing Address - Phone:662-287-7138
Mailing Address - Fax:662-287-7157
Practice Address - Street 1:2601 GETWELL RD STE 1
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-6762
Practice Address - Country:US
Practice Address - Phone:662-287-7138
Practice Address - Fax:662-287-7157
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12549208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00111263Medicaid
MS00111263Medicaid