Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0204X | Pediatric Emergency Doctor | 056233 | GA |
NPI | 1114038148 |
---|---|
Provider Name | Jennifer E Tucker |
First Address | Augusta, GA 30901-2602 |
Second Address | Augusta, GA 30912-0004 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 01/04/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
799568087A | (05) | GA |
H34458 | (02) | |
T67371 | (05) | SC |