Provider Demographics
NPI:1225764541
Name:STALEY, TANNER RYAN
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:RYAN
Last Name:STALEY
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 1:2245 CANVASBACK CT
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-8915
Mailing Address - Country:US
Mailing Address - Phone:406-381-8174
Mailing Address - Fax:
Practice Address - Street 1:211 E 2ND ST
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-2047
Practice Address - Country:US
Practice Address - Phone:406-293-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant