MEDICARE: KALISTA SHEA TUCKER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant		NC

General Provider Information

NPI Number	:	1295672491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KALISTA SHEA TUCKER

Provider Business Mailing Address
First Line	:	180 ADAMS LN
Second Line	:
City	:	BOONE
State	:	NC
Zip	:	28607-7757
Country	:	US
Telephone Number	:	980-622-6137
Fax Number	:

Provider Business Practice Location Address
First Line	:	232 BOONE HEIGHTS DR # A
Second Line	:
City	:	BOONE
State	:	NC
Zip	:	28607-4926
Country	:	US
Telephone Number	:	828-386-2663
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2026
Last Update Date	:	05/04/2026

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Directions to “ KALISTA SHEA TUCKER ” Practice Location

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