Healthcare Provider Details

I. General information

NPI: 1295672491
Provider Name (Legal Business Name): KALISTA SHEA TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 BOONE HEIGHTS DR # A
BOONE NC
28607-4926
US

IV. Provider business mailing address

180 ADAMS LN
BOONE NC
28607-7757
US

V. Phone/Fax

Practice location:
  • Phone: 828-386-2663
  • Fax:
Mailing address:
  • Phone: 980-622-6137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: