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General NPI Number Information
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NPI Number | 1053846857
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Entity Type | Individual
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Provider Name | TANNER NICHOLS DO
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Gender | Male
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Dates
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Enumeration Date | 04/29/2017
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Last Update Date | 06/19/2023
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Provider Practice Location Address
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Address Line | 2710 S RIFE MEDICAL LN
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City | ROGERS
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State | AR
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Zip | 72758-1452
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Country | US
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Telephone | 870-897-5840
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Fax |
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Provider Business Mailing Address
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Address Line | 522 S HUNT CLUB BLVD # 413
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City | APOPKA
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State | FL
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Zip | 32703-4960
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 26319
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | E-13773
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License Number State | AR
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Taxonomy #3
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 4643
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License Number State | TN
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