Basic Information
| Provider Information | |||||||||
| NPI: | 1770750101 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TUCHEK | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | P.A. -C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 S US HIGHWAY 27 | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAINT JOHNS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488792423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892243000 | ||||||||
| FaxNumber: | 9892241424 | ||||||||
| Practice Location | |||||||||
| Address1: | 1005 S US HIGHWAY 27 | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAINT JOHNS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488792423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892246897 | ||||||||
| FaxNumber: | 9892246898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2008 | ||||||||
| LastUpdateDate: | 03/24/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 5601003405 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 5601003405 | 01 | MI | STATE LICENSE | OTHER | 0C36097 | 01 | TRAVELERS MEDICARE | OTHER |