Healthcare Provider Details

I. General information

NPI: 1659961845
Provider Name (Legal Business Name): TANNER SPADE DPT, OCS, SCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2021
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 W HESSE ST
BUFFALO WY
82834-1501
US

IV. Provider business mailing address

109 W HESSE ST
BUFFALO WY
82834-1501
US

V. Phone/Fax

Practice location:
  • Phone: 307-621-0935
  • Fax: 844-409-0424
Mailing address:
  • Phone: 307-621-0935
  • Fax: 844-409-0424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-1715
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: