Provider Demographics
NPI:1487903464
Name:TUCKER, TYRONE DEMETRIUS
Entity type:Individual
Prefix:
First Name:TYRONE
Middle Name:DEMETRIUS
Last Name:TUCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 DUKE AVE
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-3800
Mailing Address - Country:US
Mailing Address - Phone:702-479-8650
Mailing Address - Fax:
Practice Address - Street 1:415 DUKE AVE
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-3800
Practice Address - Country:US
Practice Address - Phone:702-479-8650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner