Individual
ANDREA HARDISON TACKETT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD, FACC
Contact information
Practice address
1941 JOHNSON AVE, STE 101, SAN LUIS OBISPO, CA 93401-4154
(805) 782-8844
(805) 782-8859
Mailing address
1941 JOHNSON AVE, STE 101, SAN LUIS OBISPO, CA 93401-4154
(805) 782-8844
(805) 782-8859
Taxonomy
Speciality
Code
Description
License number
State
207RC0000X
Cardiovascular Disease Physician
Primary
A116056
CA
207UN0901X
Nuclear Cardiology Physician
A116056
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
GR000068680
—
CA
01
—
P00971250
RR MEDICARE
CA
01
—
ZZZ28458Z
BLUE SHIELD
CA
Enumeration date
05/30/2007
Last updated
06/25/2021
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