Healthcare Provider Details

I. General information

NPI: 1124761267
Provider Name (Legal Business Name): TUCKER DOUGLAS RIENTS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2022
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6025 LAKE RD STE 200
SAINT PAUL MN
55125-1710
US

IV. Provider business mailing address

3001 METRO DR STE 460
BLOOMINGTON MN
55425-1548
US

V. Phone/Fax

Practice location:
  • Phone: 651-999-6800
  • Fax: 833-905-0989
Mailing address:
  • Phone: 651-999-7022
  • Fax: 651-999-6970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14708
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: