Provider Demographics
NPI:1528068145
Name:TANNER, JAY B (OD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:B
Last Name:TANNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 3RD AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5809
Mailing Address - Country:US
Mailing Address - Phone:570-288-1974
Mailing Address - Fax:570-288-0288
Practice Address - Street 1:423 3RD AVE
Practice Address - Street 2:SUITE E
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5809
Practice Address - Country:US
Practice Address - Phone:570-288-1974
Practice Address - Fax:570-288-0288
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG 000400152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA410043623OtherPALMETTO GBA-RRMC
PA0011040000005Medicaid
PA0011040000003Medicaid
T30283Medicare UPIN