Healthcare Provider Details

I. General information

NPI: 1124931944
Provider Name (Legal Business Name): TANNER MATTHEW HOLBEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12200 WARWICK BLVD # 590B
NEWPORT NEWS VA
23601-2344
US

IV. Provider business mailing address

11542 CLIFF LAWN DR
CHESTER VA
23831-2005
US

V. Phone/Fax

Practice location:
  • Phone: 757-594-2074
  • Fax:
Mailing address:
  • Phone: 804-920-6961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: