Healthcare Provider Details

I. General information

NPI: 1376103606
Provider Name (Legal Business Name): TANNER JAMES ALLEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 07/11/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 E 100 N
GUNNISON UT
84634
US

IV. Provider business mailing address

64 E 100 S
GUNNISON UT
84634-7709
US

V. Phone/Fax

Practice location:
  • Phone: 435-528-7246
  • Fax:
Mailing address:
  • Phone: 435-528-7246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number5151013904
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number14018337-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: