Provider Demographics
NPI:1457785263
Name:TUCKER, KRISTEN ELAINE (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ELAINE
Last Name:TUCKER
Suffix:
Gender:F
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 1:1500 CONCORD TER
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2815
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:954-858-0404
Practice Address - Street 1:1 SHIRCLIFF WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4748
Practice Address - Country:US
Practice Address - Phone:904-308-7497
Practice Address - Fax:954-858-0404
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104439363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003140585AMedicaid
FL010132800Medicaid
GA003140585AMedicaid