Provider Demographics
NPI:1114768736
Name:TANNER, GRACIELA SUSANA (PA)
Entity type:Individual
Prefix:DR
First Name:GRACIELA
Middle Name:SUSANA
Last Name:TANNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:A53 CALLE 4
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00612-2525
Mailing Address - Country:US
Mailing Address - Phone:727-225-4605
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 11913
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00922-1913
Practice Address - Country:US
Practice Address - Phone:787-999-0753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR001710PA363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant