Provider Demographics
NPI:1295393957
Name:DEAN, TANNER (DO)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:DEAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N KANSAS ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-3124
Mailing Address - Country:US
Mailing Address - Phone:316-293-2665
Mailing Address - Fax:
Practice Address - Street 1:8533 E 32ND ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-2611
Practice Address - Country:US
Practice Address - Phone:316-293-3455
Practice Address - Fax:855-487-3302
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS94-09886207R00000X
KS05-46297207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS30004650330002Medicaid