Provider Demographics
NPI:1275382525
Name:TANNER, TONY (PSSII)
Entity type:Individual
Prefix:MR
First Name:TONY
Middle Name:
Last Name:TANNER
Suffix:
Gender:M
Credentials:PSSII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 E BROADWAY AVE STE 1214
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-3395
Mailing Address - Country:US
Mailing Address - Phone:701-581-3531
Mailing Address - Fax:
Practice Address - Street 1:3333 E BROADWAY AVE STE 1214
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-3395
Practice Address - Country:US
Practice Address - Phone:701-581-3531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1578322293Medicaid