Healthcare Provider Details

I. General information

NPI: 1396365029
Provider Name (Legal Business Name): MS. KIRA TANNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2142 N COVE BLVD
TOLEDO OH
43606-3895
US

IV. Provider business mailing address

15923 COUNTY ROAD C
WAUSEON OH
43567-9432
US

V. Phone/Fax

Practice location:
  • Phone: 419-291-2062
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Internal Medicine Physician
License Number585655
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: