Provider Demographics
NPI:1902131980
Name:TANNER, TIFFANY JANE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:JANE
Last Name:TANNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 NORTH 5TH STREET
Mailing Address - Street 2:
Mailing Address - City:BASIN
Mailing Address - State:WY
Mailing Address - Zip Code:82410
Mailing Address - Country:US
Mailing Address - Phone:307-568-3700
Mailing Address - Fax:307-586-2217
Practice Address - Street 1:525 NORTH 5TH STREET
Practice Address - Street 2:
Practice Address - City:BASIN
Practice Address - State:WY
Practice Address - Zip Code:82410
Practice Address - Country:US
Practice Address - Phone:307-568-3700
Practice Address - Fax:307-586-2217
Is Sole Proprietor?:No
Enumeration Date:2009-10-08
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPA1142363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant