Healthcare Provider Details

I. General information

NPI: 1053924415
Provider Name (Legal Business Name): TANNER STIPPICH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2020
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 MEDICAL DR STE A
LIMA OH
45804-4030
US

IV. Provider business mailing address

801 MEDICAL DR STE A
LIMA OH
45804-4030
US

V. Phone/Fax

Practice location:
  • Phone: 419-222-6622
  • Fax: 419-224-0015
Mailing address:
  • Phone: 192-226-6224
  • Fax: 419-224-0015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number50007469RX
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: