Provider Demographics
NPI:1073276259
Name:VERDUZCO, TANNER JESUS
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:JESUS
Last Name:VERDUZCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7235 OHMS LN
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-2148
Mailing Address - Country:US
Mailing Address - Phone:952-841-2345
Mailing Address - Fax:952-841-2346
Practice Address - Street 1:12000 ELM CREEK BLVD N STE 300
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7075
Practice Address - Country:US
Practice Address - Phone:952-841-2345
Practice Address - Fax:952-841-2346
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-14
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant