Provider Demographics
NPI:1982707923
Name:TANNER, KENNETH EARLE JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:EARLE
Last Name:TANNER
Suffix:JR
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 1:300 - 20TH AVE. NORTH - 9TH FLOOR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-5600
Mailing Address - Country:US
Mailing Address - Phone:615-284-1400
Mailing Address - Fax:615-284-1349
Practice Address - Street 1:300-20TH AVE. N. - 9TH FLOOR
Practice Address - Street 2:NASHVILLE MEDICAL GROUP
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-5600
Practice Address - Country:US
Practice Address - Phone:615-284-1400
Practice Address - Fax:615-284-1349
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA74363A00000X
TNPA-074363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S60547Medicare UPIN
3667594Medicare PIN