Healthcare Provider Details

I. General information

NPI: 1346230646
Provider Name (Legal Business Name): JANNA MARIE TUCK M. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 GALISTEO ST STE 8
SANTA FE NM
87505-4752
US

IV. Provider business mailing address

DEPT. 453 PO BOX 1000
MEMPHIS TN
38148-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-9870
  • Fax: 505-983-1265
Mailing address:
  • Phone: 828-575-2625
  • Fax: 828-350-2174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number108098
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberMD2017-0858
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: