Healthcare Provider Details

I. General information

NPI: 1629470992
Provider Name (Legal Business Name): TANNER KIMBER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 09/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 NORTHLAND DR
BLOOMINGTON MN
55431-4800
US

IV. Provider business mailing address

10523 FIRST TIMBERLANE DR
NORTHFIELD MN
55057-4466
US

V. Phone/Fax

Practice location:
  • Phone: 952-806-5693
  • Fax:
Mailing address:
  • Phone: 952-201-8978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number2000017447
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: