=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538795679
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TANNER SEAN HARVEY SOIDC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2020
-----------------------------------------------------
Last Update Date | 06/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 472 POLARIS AVENUE
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-862-2715
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1MRB BAS
-----------------------------------------------------
City | APO
-----------------------------------------------------
State | AA
-----------------------------------------------------
Zip | 92010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-500-0719
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1710I1002X
-----------------------------------------------------
Taxonomy Name | Independent Duty Corpsman
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------