Healthcare Provider Details

I. General information

NPI: 1902131980
Provider Name (Legal Business Name): TIFFANY JANE TANNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2009
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 BIG HORN AVE W
BASIN WY
82410-9410
US

IV. Provider business mailing address

806 BIG HORN AVE W
BASIN WY
82410-9410
US

V. Phone/Fax

Practice location:
  • Phone: 307-388-1161
  • Fax: 609-250-9938
Mailing address:
  • Phone: 307-388-1161
  • Fax: 609-250-9938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1142
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: