MEDICARE: KIRK W TANNER CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	0024094260	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760486328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIRK W TANNER CRNA

Provider Business Mailing Address
First Line	:	PO BOX 800778
Second Line	:
City	:	CHARLOTTESVILLE
State	:	VA
Zip	:	22908-0778
Country	:	US
Telephone Number	:	434-982-4228
Fax Number	:	434-924-2078

Provider Business Practice Location Address
First Line	:	1215 LEE ST
Second Line	:
City	:	CHARLOTTESVILLE
State	:	VA
Zip	:	22908-0816
Country	:	US
Telephone Number	:	434-924-0000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	09/26/2012

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