Tanner Jesus Verduzco – Physician Assistant

Key facts

NPI: 1073276259
Entity type: Individual (NPI type 1)
Primary specialty: Physician Assistant 363A00000X
Practice address: 12000 Elm Creek Blvd N Ste 300
Maple Grove, MN 55369-7075
Phone: (952) 841-2345
Fax: (952) 841-2346
NPI assigned: Oct 14, 2021
Sex: Male
Sole proprietor: Yes

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Andrew J Will MD PA Physical Medicine & Rehabilitation Physician · Edina, MN · NPI 1215003066

Medicare reassignment Care Compare group NPD (past) MN

Medicare Care Compare profile

Specialty: Physician Assistant
Education: Other, 2022
Medicare assignment: Accepts the Medicare-approved amount as payment in full
Telehealth: Offers telehealth services
Group practices: Andrew J Will MD PA (36 clinicians)

Practice addresses (Care Compare)

12000 Elm Creek Blvd N
Suite 300
Maple Grove, MN 55369-7075
Phone (952) 841-2345

7235 Ohms LN
Edina, MN 55439-2148
Phone (952) 841-2345

Merit-based Incentive Payment System (MIPS)

Final score: 79.75 of 100 (group)
Quality: 42.73
Promoting interoperability: 96
Improvement activities: 40
Cost: 66.97

Medicare participation

Medicare fee-for-service enrollment: Enrolled in MN
Eligible to order & refer: Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No

Medicare enrollment records

Enrollment ID	State	Provider type	PAC ID	Details
I20230508000958	MN	Practitioner - Physician Assistant	9335504752	Reassigns benefits to 1 organization

National Provider Directory

Medicare enrollment (NPD): Yes
Credentials: Physician Assistant

State licenses

License	State	Type	Specialty
14387	MN	MD	Clinical Social Worker

Practice roles

Organization	Specialty	Status	New patients
Andrew J Will MD PA		Past	Accepting new patients

Interoperability endpoints

Direct secure messaging: tanner.verduzco.p1@direct.tcpain.nextgenshare.com

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Physician Assistant	363A00000X			Yes

Addresses

Primary practice location

12000 Elm Creek Blvd N Ste 300
Maple Grove, MN 55369-7075

Mailing address

7235 Ohms LN
Edina, MN 55439-2148
Phone (952) 841-2345

Other practice location 1

7235 Ohms Ln
Edina, MN 55439-2148
Phone (952) 841-2345

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Dec 21, 2023.

{
    "created_epoch": "1634169600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1703116800000",
    "number": "1073276259",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7235 OHMS LN",
            "city": "EDINA",
            "state": "MN",
            "postal_code": "554392148",
            "telephone_number": "952-841-2345",
            "fax_number": "952-841-2346"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12000 ELM CREEK BLVD N STE 300",
            "city": "MAPLE GROVE",
            "state": "MN",
            "postal_code": "553697075",
            "telephone_number": "952-841-2345",
            "fax_number": "952-841-2346"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "7235 Ohms Ln",
            "address_purpose": "LOCATION",
            "city": "Edina",
            "state": "MN",
            "postal_code": "554392148",
            "country_code": "US",
            "telephone_number": "952-841-2345",
            "fax_number": "952-841-2346",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "VERDUZCO",
        "first_name": "TANNER",
        "middle_name": "JESUS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2021-10-14",
        "last_updated": "2023-12-21",
        "certification_date": "2023-12-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Maple Grove, MN

All providers in Maple Grove, MN · Physician Assistant in Minnesota

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 21, 2023. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
Order and Referring (CMS).
Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.