Provider Demographics
NPI:1477253003
Name:BOGAR TUCKER, TAMARA LAKISHA
Entity type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:LAKISHA
Last Name:BOGAR TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24471 BORREGO CIR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-5159
Mailing Address - Country:US
Mailing Address - Phone:951-433-0990
Mailing Address - Fax:
Practice Address - Street 1:995 POTRERO AVE BLDG 90
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-2859
Practice Address - Country:US
Practice Address - Phone:628-206-8683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA689467163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)