Provider Demographics
NPI:1053846857
Name:NICHOLS, TANNER (DO)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 S HUNT CLUB BLVD # 413
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-4960
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2710 S RIFE MEDICAL LN
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-1452
Practice Address - Country:US
Practice Address - Phone:870-897-5840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-29
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS263192085R0202X
ARE-137732085R0202X
TN46432085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology