Healthcare Provider Details

I. General information

NPI: 1518525260
Provider Name (Legal Business Name): TANNER COLE EARNEST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 1ST ST SW
ROCHESTER MN
55905-0001
US

IV. Provider business mailing address

359 BROOKESTONE DR SE
ROCHESTER MN
55904-3226
US

V. Phone/Fax

Practice location:
  • Phone: 507-284-2511
  • Fax:
Mailing address:
  • Phone: 432-553-0755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number2272072
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: