Provider Demographics
NPI:1225544935
Name:TUCK, ELLEN
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:TUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4916 GLENDARION DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-8027
Mailing Address - Country:US
Mailing Address - Phone:919-451-2535
Mailing Address - Fax:
Practice Address - Street 1:566 RUIN CREEK RD
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-2927
Practice Address - Country:US
Practice Address - Phone:919-461-7132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant