MEDICARE: MR. DWAYNE TATNALL

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1942811229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DWAYNE TATNALL

Provider Business Mailing Address
First Line	:	4404 W 59TH PL
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90043-3427
Country	:	US
Telephone Number	:	323-295-8780
Fax Number	:

Provider Business Practice Location Address
First Line	:	4110 SANTA FE AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90810-1439
Country	:	US
Telephone Number	:	310-847-6422
Fax Number	:

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

Provider Enumeration Date	:	08/11/2020
Last Update Date	:	08/11/2020

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