Provider Demographics
NPI:1750168530
Name:TUCKER, ALEXANDRA RUTHANN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ALEXANDRA
Middle Name:RUTHANN
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:ALEXANDRA
Other - Middle Name:RUTHANN
Other - Last Name:BUSTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:233 LIGHTBOURNE DR APT 3F
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-5396
Mailing Address - Country:US
Mailing Address - Phone:803-719-6314
Mailing Address - Fax:
Practice Address - Street 1:1202 E BUTLER RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5910
Practice Address - Country:US
Practice Address - Phone:864-627-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-13
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4914363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant