Basic Information
| Provider Information | |||||||||
| NPI: | 1417929837 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TUCKER | ||||||||
| FirstName: | SHERRI | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4401 W MEMORIAL RD | ||||||||
| Address2: | #141 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731341785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059365800 | ||||||||
| FaxNumber: | 4059365810 | ||||||||
| Practice Location | |||||||||
| Address1: | 1208 W 15TH ST | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730133001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053402100 | ||||||||
| FaxNumber: | 4053401184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 09/09/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 16293 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080161475 | 01 | OK | RAILROAD MEDICARE | OTHER | 100136700A | 05 | OK | MEDICAID |