Provider Demographics
NPI:1477177863
Name:STAAB, TANNER JORDAN
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:JORDAN
Last Name:STAAB
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 1:4060 N REED AVE APT 912
Mailing Address - Street 2:
Mailing Address - City:MAIZE
Mailing Address - State:KS
Mailing Address - Zip Code:67101-3813
Mailing Address - Country:US
Mailing Address - Phone:785-259-1516
Mailing Address - Fax:
Practice Address - Street 1:3636 N RIDGE RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1213
Practice Address - Country:US
Practice Address - Phone:316-462-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3572235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist