Provider Demographics
NPI:1194145755
Name:TUCKER, LANNING (ATC, LAT, ATR)
Entity type:Individual
Prefix:
First Name:LANNING
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:ATC, LAT, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 TWINS WAY
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-1418
Mailing Address - Country:US
Mailing Address - Phone:612-659-3694
Mailing Address - Fax:612-659-4035
Practice Address - Street 1:1 TWINS WAY
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-1418
Practice Address - Country:US
Practice Address - Phone:612-659-3694
Practice Address - Fax:612-659-4035
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25492255A2300X
TXAT10302255A2300X
FLAL3582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer