Healthcare Provider Details

I. General information

NPI: 1598267676
Provider Name (Legal Business Name): TUCKER BOONE JOHNSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2018
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6525 FRANCE AVE S STE 200
EDINA MN
55435-2176
US

IV. Provider business mailing address

6525 FRANCE AVE S STE 200
EDINA MN
55435-2176
US

V. Phone/Fax

Practice location:
  • Phone: 952-927-6501
  • Fax: 952-653-1433
Mailing address:
  • Phone: 952-927-6501
  • Fax: 952-653-1433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number12064896-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: