Healthcare Provider Details

I. General information

NPI: 1265416432
Provider Name (Legal Business Name): MICHAEL CLIFFORD TCHIDA PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7675 MADISON ST NE
FRIDLEY MN
55432-2753
US

IV. Provider business mailing address

7675 MADISON ST NE
FRIDLEY MN
55432-2753
US

V. Phone/Fax

Practice location:
  • Phone: 763-785-4500
  • Fax: 763-785-3314
Mailing address:
  • Phone: 763-785-4500
  • Fax: 763-785-3314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8865
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: