Provider Demographics
NPI:1225764541
Name:STALEY, TANNER RYAN
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:RYAN
Last Name:STALEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 RUFUS LN
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-8903
Mailing Address - Country:US
Mailing Address - Phone:406-883-2555
Mailing Address - Fax:406-883-2559
Practice Address - Street 1:104 RUFUS LN
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-8903
Practice Address - Country:US
Practice Address - Phone:406-883-2555
Practice Address - Fax:406-883-2559
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant