Provider Demographics
NPI:1104800390
Name:TUCKER, VICTOR JASON (PA-C)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:JASON
Last Name:TUCKER
Suffix:
Gender:M
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 1:20 RIVERBEND DR SW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-6066
Mailing Address - Country:US
Mailing Address - Phone:706-295-0070
Mailing Address - Fax:706-235-1618
Practice Address - Street 1:20 RIVERBEND DR SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-6066
Practice Address - Country:US
Practice Address - Phone:706-295-0070
Practice Address - Fax:706-235-1618
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3922363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP63743Medicare UPIN
GA97WCGBJMedicare ID - Type Unspecified