Provider Demographics
NPI:1902892243
Name:TUCKER, LAURA A (NP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:TUCKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:A
Other - Last Name:BALLIET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:THE NEUROSCIENCE GROUP OF NE WI
Mailing Address - Street 2:WEST PAVILION 2ND FLOOR, 130 SENCOND STREET
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2753
Mailing Address - Country:US
Mailing Address - Phone:920-725-9373
Mailing Address - Fax:920-720-7392
Practice Address - Street 1:WEST PAVILION 2 FLOOR
Practice Address - Street 2:130 SECOND STREET
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2753
Practice Address - Country:US
Practice Address - Phone:920-725-9373
Practice Address - Fax:920-720-7392
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2582033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P44806Medicare UPIN