Provider Demographics
NPI:1316489669
Name:TUCKER, BRANDON RAYE (ARNP)
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:RAYE
Last Name:TUCKER
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 WHITE DOGWOOD LANE
Mailing Address - Street 2:
Mailing Address - City:OCOE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-4878
Mailing Address - Country:US
Mailing Address - Phone:850-509-3888
Mailing Address - Fax:
Practice Address - Street 1:2110 W SUNSET BLVD STE M
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-7318
Practice Address - Country:US
Practice Address - Phone:833-873-2852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-17
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9310955363LF0000X
CANP95023449363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily