Provider Demographics
NPI:1215942057
Name:TANNER, JODY SALTERN (PA)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:SALTERN
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 1:721 1ST AVE S UNIT A
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-4723
Mailing Address - Country:US
Mailing Address - Phone:877-633-9110
Mailing Address - Fax:
Practice Address - Street 1:721 1ST AVE S UNIT A
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-4723
Practice Address - Country:US
Practice Address - Phone:877-633-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0677363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1470218Medicaid