Provider Demographics
NPI:1285106450
Name:TUCKER, MATTHEW PAUL (CRNA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:PAUL
Last Name:TUCKER
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 CABRILLO VILLAS
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-5015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4867 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5969
Practice Address - Country:US
Practice Address - Phone:913-461-9677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019043388367500000X
CA95001019367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered