Provider Demographics
NPI:1265678478
Name:DONALSON, TANNA LEE
Entity Type:Individual
Prefix:
First Name:TANNA
Middle Name:LEE
Last Name:DONALSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TANNA
Other - Middle Name:L
Other - Last Name:STROUP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 173862
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3862
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:4567 E. 9TH AVENUE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-5337
Practice Address - Country:US
Practice Address - Phone:303-320-2455
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2008-12-18
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1782363AM0700X
CO0003831363AM0700X
COPA.0003831363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO67284507Medicaid
CO412199YL2GMedicare PIN