Provider Demographics
NPI:1386857829
Name:TANNER, CAROL SUE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:SUE
Last Name:TANNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:672 W 400 S STE 201
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-3170
Mailing Address - Country:US
Mailing Address - Phone:801-369-8989
Mailing Address - Fax:801-704-9741
Practice Address - Street 1:672 W 400 S STE 201
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-3170
Practice Address - Country:US
Practice Address - Phone:801-369-8989
Practice Address - Fax:801-704-9741
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5206678-1206363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical