Healthcare Provider Details

I. General information

NPI: 1396659868
Provider Name (Legal Business Name): TANNER COLLIN KUKETZ EP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2223 S 48TH ST STE H
TEMPE AZ
85282-1011
US

IV. Provider business mailing address

800 E CURRY RD APT 3021
TEMPE AZ
85288-7057
US

V. Phone/Fax

Practice location:
  • Phone: 863-338-0993
  • Fax:
Mailing address:
  • Phone: 863-338-0993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number2000017
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: