Provider Demographics
NPI:1386688307
Name:TANNER, DOUGLAS EVAN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:EVAN
Last Name:TANNER
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14141-1442
Mailing Address - Country:US
Mailing Address - Phone:716-592-3635
Mailing Address - Fax:
Practice Address - Street 1:210 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:14141-1442
Practice Address - Country:US
Practice Address - Phone:716-592-3635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005527-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9514284AOAOtherINDEPENDENT HEALTH
NY0003153OtherGHI
NY00026501103OtherUNIVERA
NY000570091007OtherBCBS
NY01666426Medicaid
NYP00459731OtherRRMEDICARE
NY0003153OtherGHI
NY9514284AOAOtherINDEPENDENT HEALTH