Healthcare Provider Details

I. General information

NPI: 1831407147
Provider Name (Legal Business Name): BRAD TANNER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2010
Last Update Date: 09/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5323 WOODROW ST STE 102
MURRAY UT
84107-5853
US

IV. Provider business mailing address

5444 SOUTH GREEN STREET
MURRAY UT
84123
US

V. Phone/Fax

Practice location:
  • Phone: 801-913-1010
  • Fax: 801-262-3897
Mailing address:
  • Phone: 801-284-1702
  • Fax: 801-262-3897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number7777106-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: