Basic Information
| Provider Information | |||||||||
| NPI: | 1578160214 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TUCKER | ||||||||
| FirstName: | LANDRY | ||||||||
| MiddleName: | ROSS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1308 BLUEBONNET TRL | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760135004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177094052 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 901 W BEN WHITE BLVD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787046903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124472211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2020 | ||||||||
| LastUpdateDate: | 10/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.