Healthcare Provider Details

I. General information

NPI: 1225698822
Provider Name (Legal Business Name): TANNER DEAN HAWK PT, DPT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 06/10/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5723 S 30TH GLN
PHOENIX AZ
85041-3528
US

IV. Provider business mailing address

5723 S 30TH GLN
PHOENIX AZ
85041-3528
US

V. Phone/Fax

Practice location:
  • Phone: 480-544-0955
  • Fax:
Mailing address:
  • Phone: 480-544-0955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberLPT30714
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-030714
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: