Provider Demographics
NPI:1225013634
Name:TANNER, KATIE L (PA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:L
Last Name:TANNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:819 MAIN ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-4244
Practice Address - Country:US
Practice Address - Phone:701-683-4134
Practice Address - Fax:701-683-4094
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0102363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND05171Medicaid
ND19659OtherNDBS
ND19659OtherNDBS
ND353852Medicare ID - Type UnspecifiedMEDICARE RHC FACILITY
ND05171Medicaid