Healthcare Provider Details

I. General information

NPI: 1285366278
Provider Name (Legal Business Name): TANNER HAMBY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 INGLESIDE AVENUE
MACON GA
31204
US

IV. Provider business mailing address

2140 INGLESIDE AVE APT J6
MACON GA
31204-2063
US

V. Phone/Fax

Practice location:
  • Phone: 770-896-3232
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: