Provider Demographics
NPI:1033454871
Name:FRITSCHKA, TANNER PAULSON
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:PAULSON
Last Name:FRITSCHKA
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 1:407 STATE AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2670
Mailing Address - Country:US
Mailing Address - Phone:195-887-1137
Mailing Address - Fax:
Practice Address - Street 1:407 STATE AVE
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2670
Practice Address - Country:US
Practice Address - Phone:719-588-7113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-05
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1886171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist