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General NPI Number Information
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NPI Number | 1447837166
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Entity Type | Individual
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Provider Name | TANNER SOUZA DO
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Gender | Male
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Dates
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Enumeration Date | 03/27/2021
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Last Update Date | 08/23/2024
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Provider Practice Location Address
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Address Line | 1130 W PRAIRIE AVE
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City | COEUR D ALENE
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State | ID
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Zip | 83815-8780
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Country | US
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Telephone | 208-209-0288
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Fax | 208-209-0289
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Provider Business Mailing Address
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Address Line | PO BOX 1517
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City | PENDLETON
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State | OR
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Zip | 97801-0410
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Country | US
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Telephone | 541-278-4332
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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 | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | DO3477
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License Number State | NV
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 0-1993
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License Number State | ID
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