Provider Demographics
NPI:1962243444
Name:TUCKER, NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12596 W BAYAUD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-2035
Mailing Address - Country:US
Mailing Address - Phone:720-638-7500
Mailing Address - Fax:720-812-5134
Practice Address - Street 1:12596 W BAYAUD AVE STE 100
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-2035
Practice Address - Country:US
Practice Address - Phone:720-638-7500
Practice Address - Fax:720-812-5134
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-06
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
COPA.8882363A00000X
COPA.0008612363AS0400X
COPA.8612363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical