Provider Demographics
NPI:1598142457
Name:TUCKER, BRANDON (DPM)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 WILLMAR AVE SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3556
Mailing Address - Country:US
Mailing Address - Phone:320-231-5000
Mailing Address - Fax:
Practice Address - Street 1:101 WILLMAR AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3556
Practice Address - Country:US
Practice Address - Phone:320-231-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-29
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN999213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist