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: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 W PRAIRIE AVE
COEUR D ALENE ID
83815-8780
US

IV. Provider business mailing address

PO BOX 1517
PENDLETON OR
97801-0410
US

V. Phone/Fax

Practice location:
  • Phone: 208-209-0288
  • Fax: 208-209-0289
Mailing address:
  • Phone: 541-278-4332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberDO3477
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0-1993
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: