Provider Demographics
NPI:1164055018
Name:TANNER, KRISTINA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:
Other - Last Name:TANNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:52 MEDICAL PARK DR E STE 220
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35235-3428
Mailing Address - Country:US
Mailing Address - Phone:205-838-4747
Mailing Address - Fax:205-383-1251
Practice Address - Street 1:52 MEDICAL PARK DR E STE 220
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3428
Practice Address - Country:US
Practice Address - Phone:205-838-4747
Practice Address - Fax:205-383-1251
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA1579363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPA1579OtherALABAMA LICENSE