Provider Demographics
NPI:1346230646
Name:TUCK, JANNA MARIE (M D)
Entity Type:Individual
Prefix:DR
First Name:JANNA
Middle Name:MARIE
Last Name:TUCK
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT. 453 PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:1651 GALISTEO ST STE 8
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4752
Practice Address - Country:US
Practice Address - Phone:505-820-9870
Practice Address - Fax:505-983-1265
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108098207K00000X
NMMD2017-0858207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM55771718Medicaid
NM637008AU6TOtherMEDICARE PTAN
MO030003552Medicare PIN
MO208710004Medicaid