Provider Demographics
NPI:1962201491
Name:DAVIS, TANNER
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:DAVIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4707 SNOW WHITE TER
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5829
Mailing Address - Country:US
Mailing Address - Phone:618-980-1210
Mailing Address - Fax:
Practice Address - Street 1:8101 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63117-1103
Practice Address - Country:US
Practice Address - Phone:314-726-2124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-08
Last Update Date:2025-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025006202363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty