Provider Demographics
NPI:1962108456
Name:REESE, TANNER RAY (PA-C)
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:RAY
Last Name:REESE
Suffix:
Gender:M
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 1:23922 DULZURA
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78261-2970
Mailing Address - Country:US
Mailing Address - Phone:385-238-0409
Mailing Address - Fax:
Practice Address - Street 1:900 THARP RD
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95993-9159
Practice Address - Country:US
Practice Address - Phone:916-406-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA62480363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant