Healthcare Provider Details

I. General information

NPI: 1801477013
Provider Name (Legal Business Name): TOMMIE LEE JAMES III PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3270 W LAKE ST
MINNEAPOLIS MN
55416-4512
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 612-775-1800
  • Fax:
Mailing address:
  • Phone: 612-262-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13971
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: