Provider Demographics
NPI:1033416565
Name:TANNER, CARLY (PA)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:
Other - Last Name:PIRROTTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:151 SOUTHHALL LN
Mailing Address - Street 2:STE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7176
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:2835 W DE LEON ST STE 103
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4130
Practice Address - Country:US
Practice Address - Phone:813-875-7333
Practice Address - Fax:813-875-8833
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-18
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105781363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004349100Medicaid
FLFB102ZMedicare PIN