Provider Demographics
NPI:1780800300
Name:TUCK, TERRY M (NP-BC)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:M
Last Name:TUCK
Suffix:
Gender:F
Credentials:NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5342 AUTUMNLEAF DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23234-2806
Mailing Address - Country:US
Mailing Address - Phone:804-504-8764
Mailing Address - Fax:804-504-8845
Practice Address - Street 1:2820 NORMANDY DR
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9372
Practice Address - Country:US
Practice Address - Phone:804-504-8764
Practice Address - Fax:804-504-8845
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024067536363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC10279 00X494N13OtherPROVIDER IDENTIFIER
VA00X494N13Medicare PIN
VA015314R79Medicare PIN
VA015314R80Medicare PIN