Provider Demographics
NPI:1366786386
Name:TUCKER, REBECCA SUE (PA)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:SUE
Other - Last Name:PEDROZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2340 SPRING FOREST RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-7528
Mailing Address - Country:US
Mailing Address - Phone:866-389-2727
Mailing Address - Fax:
Practice Address - Street 1:2340 SPRING FOREST RD
Practice Address - Street 2:MINUTE CLINIC
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-7528
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22559363AM0700X
NC0010-05389363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC20-3555819OtherTAX ID