Healthcare Provider Details

I. General information

NPI: 1306424692
Provider Name (Legal Business Name): TANNER CROSHAW PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3970 W ANN RD STE 100
NORTH LAS VEGAS NV
89031-3853
US

IV. Provider business mailing address

3970 W ANN RD STE 100
NORTH LAS VEGAS NV
89031-3853
US

V. Phone/Fax

Practice location:
  • Phone: 702-747-4799
  • Fax: 702-747-4667
Mailing address:
  • Phone: 702-747-4799
  • Fax: 702-747-4667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number1179657
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: