Healthcare Provider Details

I. General information

NPI: 1023859113
Provider Name (Legal Business Name): TANNER JAMES BLANK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 09/12/2026
Certification Date: 09/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 HOSPITAL DR STE 203
HOLYOKE MA
01040-6614
US

IV. Provider business mailing address

2 HOSPITAL DR STE 203
HOLYOKE MA
01040-6614
US

V. Phone/Fax

Practice location:
  • Phone: 413-535-4785
  • Fax:
Mailing address:
  • Phone: 413-535-4785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberPA102824
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: