Healthcare Provider Details

I. General information

NPI: 1780443473
Provider Name (Legal Business Name): TANNER SHAWN MESSER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2024
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 LITTLE WINGS LOOP SW
LOS LUNAS NM
87031-6339
US

IV. Provider business mailing address

490 LITTLE WINGS LOOP SW
LOS LUNAS NM
87031-6339
US

V. Phone/Fax

Practice location:
  • Phone: 505-206-8701
  • Fax:
Mailing address:
  • Phone: 505-206-8701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: