Provider Demographics
NPI:1487096434
Name:TUCKETT, JOEL DENNIS
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:DENNIS
Last Name:TUCKETT
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 1:1932 10TH AVE E
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-1614
Mailing Address - Country:US
Mailing Address - Phone:208-757-3937
Mailing Address - Fax:
Practice Address - Street 1:1932 10TH AVE E
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-1614
Practice Address - Country:US
Practice Address - Phone:208-757-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9317826163W00000X
UT93089367500000X
MN215610-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse