=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679610125
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMRA GEAN EMERSON O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2007
-----------------------------------------------------
Last Update Date | 09/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1920 1ST AVE
-----------------------------------------------------
City | ANOKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55303-2437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-427-4000
-----------------------------------------------------
Fax | 763-433-2609
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 BRIDGE SQUARE 101
-----------------------------------------------------
City | ANOKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55303-2463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-421-4334
-----------------------------------------------------
Fax | 763-421-4617
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2078
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------