Basic Information
| Provider Information | |||||||||
| NPI: | 1770154478 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TUCKER | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3900 CITY AVE APT M1119 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191312925 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 10 SHURS LN STE 203 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191272123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154821234 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2021 | ||||||||
| LastUpdateDate: | 07/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MT223663 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.