Provider Demographics
NPI:1962580480
Name:TANNER, JERRY ROSS II (DO)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:ROSS
Last Name:TANNER
Suffix:II
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:J.
Other - Middle Name:ROSS
Other - Last Name:TANNER
Other - Suffix:II
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:2841 DEBARR RD STE 43
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-2967
Mailing Address - Country:US
Mailing Address - Phone:907-274-7847
Mailing Address - Fax:907-274-7845
Practice Address - Street 1:2841 DEBARR RD STE 43
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2967
Practice Address - Country:US
Practice Address - Phone:907-274-7847
Practice Address - Fax:907-274-7845
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5561207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
F37376Medicare UPIN