MEDICARE: TUCKER J ANNIS

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	163W00000X	Registered Nurse	228652-1	MN

General Provider Information

NPI Number	:	1487138673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TUCKER J ANNIS

Provider Business Mailing Address
First Line	:	1619 GRAND ST NE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55413-1031
Country	:	US
Telephone Number	:	715-892-8888
Fax Number	:

Provider Business Practice Location Address
First Line	:	1619 GRAND ST NE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55413-1031
Country	:	US
Telephone Number	:	715-892-8888
Fax Number	:

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

Provider Enumeration Date	:	09/24/2018
Last Update Date	:	09/24/2018

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