Provider Demographics
NPI:1598267676
Name:JOHNSON, TUCKER BOONE (PA-C)
Entity Type:Individual
Prefix:
First Name:TUCKER
Middle Name:BOONE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6525 FRANCE AVE S STE 200
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2176
Mailing Address - Country:US
Mailing Address - Phone:952-927-6501
Mailing Address - Fax:952-653-1433
Practice Address - Street 1:6525 FRANCE AVE S STE 200
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2176
Practice Address - Country:US
Practice Address - Phone:952-927-6501
Practice Address - Fax:952-653-1433
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
UT12064896-1206363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical