Healthcare Provider Details

I. General information

NPI: 1497611446
Provider Name (Legal Business Name): TANNER DAVIDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2026
Last Update Date: 01/02/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

589 S STATE ST
PROVO UT
84606-5056
US

IV. Provider business mailing address

589 S STATE ST
PROVO UT
84606-5056
US

V. Phone/Fax

Practice location:
  • Phone: 801-429-2000
  • Fax: 801-429-2001
Mailing address:
  • Phone: 801-429-2000
  • Fax: 801-429-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number139697313102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: