Provider Demographics
NPI:1023000411
Name:TANNER, JAMES
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:TANNER
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 1:341 MDG 7300 NORTH PERIMETER ROAD
Mailing Address - Street 2:
Mailing Address - City:MALMSTROM AFB
Mailing Address - State:MT
Mailing Address - Zip Code:59402-6780
Mailing Address - Country:US
Mailing Address - Phone:406-731-4456
Mailing Address - Fax:
Practice Address - Street 1:341 MDG 7300 NORTH PERIMETER ROAD
Practice Address - Street 2:
Practice Address - City:MALMSTROM AFB
Practice Address - State:MT
Practice Address - Zip Code:59402-6780
Practice Address - Country:US
Practice Address - Phone:406-731-4456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1316225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist