Individual
SHANNON TUCKER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
1215 LEE ST, CHARLOTTESVILLE, VA 22908-4500
(434) 243-3090
(434) 244-9445
Mailing address
PO BOX 9007, CHARLOTTESVILLE, VA 22906-9007
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
0110005762
VA
363AM0700X
Medical Physician Assistant
PA00245
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
05059577
—
MS
Enumeration date
04/10/2015
Last updated
09/13/2017
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