Healthcare Provider Details

I. General information

NPI: 1275215857
Provider Name (Legal Business Name): TANNER CLARK BROOKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6026 NW 1ST PL STE 20
GAINESVILLE FL
32607-6062
US

IV. Provider business mailing address

4960 SW 72ND AVE STE 405
MIAMI FL
33155-5506
US

V. Phone/Fax

Practice location:
  • Phone: 352-332-3353
  • Fax: 352-333-9035
Mailing address:
  • Phone: 469-458-9222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA064486
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: