Provider Demographics
NPI:1902346109
Name:ANDERSON, TANNER
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:ANDERSON
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 1:5012 S US HWY 75, SUITE 300
Mailing Address - Street 2:ATTN BILLING
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020
Mailing Address - Country:US
Mailing Address - Phone:903-416-7544
Mailing Address - Fax:
Practice Address - Street 1:3126 W FM 120
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-1249
Practice Address - Country:US
Practice Address - Phone:903-416-7544
Practice Address - Fax:903-416-7545
Is Sole Proprietor?:No
Enumeration Date:2017-03-07
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP133514363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3691941-02Medicaid
TX3691941-02Medicaid