Healthcare Provider Details

I. General information

NPI: 1790598597
Provider Name (Legal Business Name): TANNER HAWKINSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2025
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 HUEBNER RD
FORT RILEY KS
66442-4030
US

IV. Provider business mailing address

507 AUGUSTA WAY APT 105
MANHATTAN KS
66502-7199
US

V. Phone/Fax

Practice location:
  • Phone: 785-239-3627
  • Fax:
Mailing address:
  • Phone: 402-618-2991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: