Healthcare Provider Details

I. General information

NPI: 1265497853
Provider Name (Legal Business Name): BARRY TANNE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 S GRANITE AVE
GRANITE FALLS WA
98252
US

IV. Provider business mailing address

PO BOX 1650 403 S GRANITE AVE
GRANITE FALLS WA
98252-1650
US

V. Phone/Fax

Practice location:
  • Phone: 360-691-7711
  • Fax: 360-691-7864
Mailing address:
  • Phone: 360-691-7711
  • Fax: 360-691-7864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00017729
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: