Healthcare Provider Details

I. General information

NPI: 1720904584
Provider Name (Legal Business Name): TANNER MITCHELL SHIELDS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

982055 NEBRASKA MEDICAL CTR
OMAHA NE
68198-2005
US

IV. Provider business mailing address

982055 NEBRASKA MEDICAL CTR
OMAHA NE
68198-2005
US

V. Phone/Fax

Practice location:
  • Phone: 402-559-0390
  • Fax: 402-559-0380
Mailing address:
  • Phone: 402-559-0390
  • Fax: 402-559-0380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number10663
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: