Healthcare Provider Details

I. General information

NPI: 1144601865
Provider Name (Legal Business Name): TANNER D MITTON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 PARKWAY DR STE A
BLACKFOOT ID
83221-1656
US

IV. Provider business mailing address

1355 PARKWAY DR STE A
BLACKFOOT ID
83221-1656
US

V. Phone/Fax

Practice location:
  • Phone: 986-275-0003
  • Fax: 986-275-0005
Mailing address:
  • Phone: 986-275-0003
  • Fax: 986-275-0005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1262
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: