Provider Demographics
NPI:1275804270
Name:TANNER, ANTHONY T
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:T
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:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:HURLEY
Mailing Address - State:MS
Mailing Address - Zip Code:39555-0850
Mailing Address - Country:US
Mailing Address - Phone:228-588-2938
Mailing Address - Fax:228-588-9399
Practice Address - Street 1:7001 HWY 614
Practice Address - Street 2:
Practice Address - City:HURLEY
Practice Address - State:MS
Practice Address - Zip Code:39555
Practice Address - Country:US
Practice Address - Phone:228-588-2938
Practice Address - Fax:228-588-9399
Is Sole Proprietor?:No
Enumeration Date:2012-01-23
Last Update Date:2020-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR205397-4363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN500007468Medicare PIN