MEDICARE: IVAN BRANDON TANNER

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	363A00000X	Physician Assistant	PA9121206	FL

General Provider Information

NPI Number	:	1831044106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVAN BRANDON TANNER

Provider Business Mailing Address
First Line	:	2100 N WICKHAM RD
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32935-8110
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2100 N WICKHAM RD
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32935-8110
Country	:	US
Telephone Number	:	321-752-7100
Fax Number	:

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

Provider Enumeration Date	:	03/03/2026
Last Update Date	:	03/03/2026

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Directions to “ IVAN BRANDON TANNER ” Practice Location

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