Provider Demographics
NPI:1225867351
Name:LAZARUS, TANNER JACKSON
Entity type:Individual
Prefix:MR
First Name:TANNER
Middle Name:JACKSON
Last Name:LAZARUS
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 1:314 S UNIVERSITY AVE APT 1212
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5257
Mailing Address - Country:US
Mailing Address - Phone:870-688-3337
Mailing Address - Fax:
Practice Address - Street 1:314 S UNIVERSITY AVE APT 1212
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5257
Practice Address - Country:US
Practice Address - Phone:870-688-3337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program