=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811878341
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TANNER KEITH REVIS PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2025
-----------------------------------------------------
Last Update Date | 10/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1256 HENDERSONVILLE RD
-----------------------------------------------------
City | ASHEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28803-1905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-412-5330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1256 HENDERSONVILLE RD
-----------------------------------------------------
City | ASHEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28803-1905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-412-5330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | P24366
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------