Basic Information
| Provider Information | |||||||||
| NPI: | 1831184381 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TUCKERMAN | ||||||||
| FirstName: | MYRA | ||||||||
| MiddleName: | BETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1790 30TH ST. | ||||||||
| Address2: | SUITE 308 | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034400205 | ||||||||
| FaxNumber: | 3034400209 | ||||||||
| Practice Location | |||||||||
| Address1: | 1790 30TH ST | ||||||||
| Address2: | SUITE 308 | ||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803011022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034400205 | ||||||||
| FaxNumber: | 3034400209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 08/15/2008 | ||||||||
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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 | 45139 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0191671 | 05 | OH | MEDICAID | 080188923 | 01 | RAILROAD MEDICARE | OTHER |