Provider Demographics
NPI:1477288801
Name:SMITH, TANNER R (PA)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
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Other - First Name:
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Mailing Address - Street 1:2620 N 140TH AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2437
Mailing Address - Country:US
Mailing Address - Phone:623-219-4777
Mailing Address - Fax:623-219-4778
Practice Address - Street 1:2620 N 140TH AVE STE 103
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2437
Practice Address - Country:US
Practice Address - Phone:623-219-4777
Practice Address - Fax:623-219-4778
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2022-12-14
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Provider Licenses
StateLicense IDTaxonomies
AZ9328363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant