Healthcare Provider Details

I. General information

NPI: 1366091779
Provider Name (Legal Business Name): NATHANIEL FREEMAN TANNER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2019
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HYGEIA DR STE 1360
NEWARK DE
19713-2049
US

IV. Provider business mailing address

200 HYGEIA DR STE 1360
NEWARK DE
19713-2049
US

V. Phone/Fax

Practice location:
  • Phone: 302-623-1929
  • Fax: 302-368-7943
Mailing address:
  • Phone: 302-623-1929
  • Fax: 302-368-7943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5-0001340
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: