Provider Demographics
NPI:1487188363
Name:MORTENSON, TANNER ROSS (DO)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:ROSS
Last Name:MORTENSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5505 S 900 E STE 240
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7210
Mailing Address - Country:US
Mailing Address - Phone:801-783-5011
Mailing Address - Fax:
Practice Address - Street 1:5505 S 900 E STE 240
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84117-7210
Practice Address - Country:US
Practice Address - Phone:801-783-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A17016207R00000X
UT12322379-1204207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program