Provider Demographics
NPI:1902566466
Name:TUCKER, HARRISON MCCARTNEY
Entity Type:Individual
Prefix:
First Name:HARRISON
Middle Name:MCCARTNEY
Last Name:TUCKER
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 1:6700 RICHFIELD PKWY APT 326
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-7523
Mailing Address - Country:US
Mailing Address - Phone:715-501-8930
Mailing Address - Fax:
Practice Address - Street 1:6250 EXCELSIOR BLVD STE 103
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2735
Practice Address - Country:US
Practice Address - Phone:763-614-0363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-26
Last Update Date:2021-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00055236225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist