Healthcare Provider Details

I. General information

NPI: 1700291648
Provider Name (Legal Business Name): SAVANNAH TANNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 06/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 PASEO DE PERALTA
SANTA FE NM
87501-1922
US

IV. Provider business mailing address

707 PASEO DE PERALTA
SANTA FE NM
87501-1922
US

V. Phone/Fax

Practice location:
  • Phone: 505-989-8707
  • Fax: 505-989-3536
Mailing address:
  • Phone: 505-989-8707
  • Fax: 505-989-3536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2014-0033
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: