Healthcare Provider Details

I. General information

NPI: 1669982740
Provider Name (Legal Business Name): TANNER BO CARLSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2017
Last Update Date: 10/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E MONROE ST STE 101
GLOBE AZ
85501-1304
US

IV. Provider business mailing address

PO BOX 1641
GLOBE AZ
85502-1641
US

V. Phone/Fax

Practice location:
  • Phone: 928-425-8200
  • Fax: 928-425-8406
Mailing address:
  • Phone: 928-425-8200
  • Fax: 928-425-8406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number6896
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: