Provider Demographics
NPI:1336728336
Name:TUCKER, JOSEPH A (HIS)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:A
Last Name:TUCKER
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3704
Mailing Address - Country:US
Mailing Address - Phone:618-624-4471
Mailing Address - Fax:
Practice Address - Street 1:400 SW WARD RD
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64081-2447
Practice Address - Country:US
Practice Address - Phone:816-347-9090
Practice Address - Fax:816-347-9092
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020019100237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist