Healthcare Provider Details

I. General information

NPI: 1386688307
Provider Name (Legal Business Name): DOUGLAS EVAN TANNER PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 04/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 E MAIN ST
SPRINGVILLE NY
14141-1442
US

IV. Provider business mailing address

210 E MAIN ST
SPRINGVILLE NY
14141-1442
US

V. Phone/Fax

Practice location:
  • Phone: 716-592-3635
  • Fax:
Mailing address:
  • Phone: 716-592-3635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number005527-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: