Provider Demographics
NPI:1144601865
Name:MITTON, TANNER D (PA-C)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:D
Last Name:MITTON
Suffix:
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 1:950 HOSPITAL WAY
Mailing Address - Street 2:STE A
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2762
Mailing Address - Country:US
Mailing Address - Phone:208-478-4522
Mailing Address - Fax:208-712-6868
Practice Address - Street 1:950 HOSPITAL WAY
Practice Address - Street 2:STE A
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2762
Practice Address - Country:US
Practice Address - Phone:208-478-4522
Practice Address - Fax:208-712-6868
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IDPA-1262363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20007180Medicare PIN