Provider Demographics
NPI:1427155308
Name:TANIS, MICHAEL DEAN (FNP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEAN
Last Name:TANIS
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:211 W PINE LAKE DR
Practice Address - Street 2:
Practice Address - City:NEWAYGO
Practice Address - State:MI
Practice Address - Zip Code:49337-8029
Practice Address - Country:US
Practice Address - Phone:231-652-1631
Practice Address - Fax:616-267-9047
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704123034363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP17710018Medicare PIN
MIP17700002Medicare PIN
P67235Medicare UPIN