Healthcare Provider Details

I. General information

NPI: 1831044106
Provider Name (Legal Business Name): IVAN BRANDON TANNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2026
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2708 W SAINT ISABEL ST
TAMPA FL
33607-6320
US

IV. Provider business mailing address

2708 W SAINT ISABEL ST
TAMPA FL
33607-6320
US

V. Phone/Fax

Practice location:
  • Phone: 813-877-7434
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9121206
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: