Provider Demographics
NPI:1275628968
Name:TANNER, PAMELA W (DC)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:W
Last Name:TANNER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CHRISTINA PL
Mailing Address - Street 2:
Mailing Address - City:PEVELY
Mailing Address - State:MO
Mailing Address - Zip Code:63070-1646
Mailing Address - Country:US
Mailing Address - Phone:636-296-4000
Mailing Address - Fax:636-282-8530
Practice Address - Street 1:2090 ELM DR
Practice Address - Street 2:STE B
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-4192
Practice Address - Country:US
Practice Address - Phone:636-296-4000
Practice Address - Fax:636-282-8530
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO6005111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU43461Medicare UPIN