Provider Demographics
NPI:1174625925
Name:TUCKER, JESSE RAYMOND (CRNA)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:RAYMOND
Last Name:TUCKER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 VILLAGE SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-2850
Mailing Address - Country:US
Mailing Address - Phone:910-892-7664
Mailing Address - Fax:
Practice Address - Street 1:800 TILGHMAN DR
Practice Address - Street 2:
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-5510
Practice Address - Country:US
Practice Address - Phone:910-892-1000
Practice Address - Fax:910-891-6032
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC031777367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC062995OtherNC BOARD OF NURSING VERIF