Provider Demographics
NPI:1760298491
Name:TUCKER, MARY ROSE SAN PEDRO
Entity type:Individual
Prefix:
First Name:MARY ROSE
Middle Name:SAN PEDRO
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20614 CREEK RIV
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78259-2084
Mailing Address - Country:US
Mailing Address - Phone:919-273-2500
Mailing Address - Fax:
Practice Address - Street 1:7400 MERTON MINTER ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4404
Practice Address - Country:US
Practice Address - Phone:210-617-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-07
Last Update Date:2024-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX843454163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine