Provider Demographics
NPI:1407114291
Name:TACKIE, NANA YAA (MD)
Entity type:Individual
Prefix:DR
First Name:NANA
Middle Name:YAA
Last Name:TACKIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NANA
Other - Middle Name:YAA
Other - Last Name:AWUAH-NYAMEKYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1027 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3409
Mailing Address - Country:US
Mailing Address - Phone:218-847-5611
Mailing Address - Fax:218-847-0881
Practice Address - Street 1:5825 BUFORD HWY STE 300
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-2504
Practice Address - Country:US
Practice Address - Phone:770-209-2787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106015207P00000X
GA69976207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1407114291Medicaid
MN930004410Medicare PIN