Provider Demographics
NPI:1194380501
Name:TANNER, MATTHEW A
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:TANNER
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 1:3276 MURRAY PARIS RD
Mailing Address - Street 2:
Mailing Address - City:HAZEL
Mailing Address - State:KY
Mailing Address - Zip Code:42049-8403
Mailing Address - Country:US
Mailing Address - Phone:859-285-7336
Mailing Address - Fax:
Practice Address - Street 1:2001 CHARLOTTE AVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2032
Practice Address - Country:US
Practice Address - Phone:615-321-3277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant