Provider Demographics
NPI:1417169038
Name:TANNER, JEFFREY A (MPT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:TANNER
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 SNYDERS RUN
Mailing Address - Street 2:
Mailing Address - City:GANDEEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25243-8704
Mailing Address - Country:US
Mailing Address - Phone:304-927-6249
Mailing Address - Fax:304-927-6837
Practice Address - Street 1:200 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:WV
Practice Address - Zip Code:25276-1050
Practice Address - Country:US
Practice Address - Phone:304-927-6249
Practice Address - Fax:304-927-6837
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT001303225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVPT001303OtherWV BD OF PHYSICAL THERAPY