Provider Demographics
NPI:1164962064
Name:MIXON, TANNER (CRNA)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:MIXON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 KINGSFORD DR
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-6162
Mailing Address - Country:US
Mailing Address - Phone:662-312-9522
Mailing Address - Fax:
Practice Address - Street 1:2315 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2201
Practice Address - Country:US
Practice Address - Phone:916-734-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-27
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201701285CRNA367500000X
CA95001358367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered