Provider Demographics
NPI:1720532781
Name:TUCKER, PAMELA
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:TUCKER
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 1:2600 WOODMEADOW DR SE
Mailing Address - Street 2:APT. 303
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8039
Mailing Address - Country:US
Mailing Address - Phone:616-308-5310
Mailing Address - Fax:616-336-2475
Practice Address - Street 1:2600 WOODMEADOW DR SE
Practice Address - Street 2:APT. 303
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8039
Practice Address - Country:US
Practice Address - Phone:616-308-5310
Practice Address - Fax:616-336-2475
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other