Healthcare Provider Details

I. General information

NPI: 1962925180
Provider Name (Legal Business Name): TANNER ROY WEBSTER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 07/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 N HIGLEY RD
GILBERT AZ
85234-1604
US

IV. Provider business mailing address

4838 E BASELINE RD STE 108
MESA AZ
85206-4672
US

V. Phone/Fax

Practice location:
  • Phone: 480-543-2600
  • Fax:
Mailing address:
  • Phone: 480-981-2400
  • Fax: 480-981-2407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA1417
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: