Basic Information
| Provider Information | |||||||||
| NPI: | 1033532817 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TUCKER | ||||||||
| FirstName: | BAILEY | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 FRANK LLOYD WRIGHT DRIVE | ||||||||
| Address2: | SUITE J2000 | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347476766 | ||||||||
| FaxNumber: | 7342223100 | ||||||||
| Practice Location | |||||||||
| Address1: | 4200 WHITEHALL DR | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349950308 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2014 | ||||||||
| LastUpdateDate: | 08/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 06/04/2018 | ||||||||
| NPIReactivationDate: | 06/20/2018 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.