Healthcare Provider Details

I. General information

NPI: 1447837166
Provider Name (Legal Business Name): TANNER SOUZA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2021
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 W CANFIELD AVE
COEUR D ALENE ID
83815-9764
US

IV. Provider business mailing address

919 W CANFIELD AVE
COEUR D ALENE ID
83815-9764
US

V. Phone/Fax

Practice location:
  • Phone: 208-758-0560
  • Fax:
Mailing address:
  • Phone: 208-758-0560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0-1993
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: