Provider Demographics
NPI:1124079504
Name:TUCK, DELORES ANN (CRNA)
Entity type:Individual
Prefix:MS
First Name:DELORES
Middle Name:ANN
Last Name:TUCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 CREEDMOOR RD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-6730
Mailing Address - Country:US
Mailing Address - Phone:919-906-4721
Mailing Address - Fax:
Practice Address - Street 1:6300 CREEDMOOR RD
Practice Address - Street 2:SUITE 170
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-6730
Practice Address - Country:US
Practice Address - Phone:919-906-4721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102920367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8050545Medicaid
NC2614618FMedicare PIN
NC8050545Medicaid