Healthcare Provider Details

I. General information

NPI: 1427155308
Provider Name (Legal Business Name): MICHAEL DEAN TANIS FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W PINE LAKE DR
NEWAYGO MI
49337-8029
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 231-652-1631
  • Fax: 616-267-9047
Mailing address:
  • Phone: 616-486-6790
  • Fax: 616-486-6702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704123034
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: