Healthcare Provider Details

I. General information

NPI: 1407911142
Provider Name (Legal Business Name): JASON MATHEW TANNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5151 N 9TH AVE
PENSACOLA FL
32504-8721
US

IV. Provider business mailing address

4900 BAYOU BLVD SUITE 205
PENSACOLA FL
32503-2525
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-4500
  • Fax:
Mailing address:
  • Phone: 850-476-2387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberME 95762
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: