Healthcare Provider Details

I. General information

NPI: 1043731870
Provider Name (Legal Business Name): TANNER WALLEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2017
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12255 DEPAUL DRIVE SUITE 500
SAINT LOUIS MO
63044
US

IV. Provider business mailing address

12255 DEPAUL DRIVE SUITE 500
SAINT LOUIS MO
63040
US

V. Phone/Fax

Practice location:
  • Phone: 314-209-5180
  • Fax:
Mailing address:
  • Phone: 314-209-5180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2020024367
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2020024367
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: