Healthcare Provider Details

I. General information

NPI: 1538746953
Provider Name (Legal Business Name): JORDAN FRANCIS TANNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2199 N MERRITT CREEK LOOP
COEUR D ALENE ID
83814-4949
US

IV. Provider business mailing address

33024 SE 44TH ST
FALL CITY WA
98024-8703
US

V. Phone/Fax

Practice location:
  • Phone: 208-665-7546
  • Fax:
Mailing address:
  • Phone: 425-941-0573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number3871694
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: