Provider Demographics
NPI:1497370456
Name:WINGER, TANNER
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:WINGER
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:PO BOX 30015
Mailing Address - Street 2:DEPT 214
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0015
Mailing Address - Country:US
Mailing Address - Phone:435-787-2000
Mailing Address - Fax:435-787-1913
Practice Address - Street 1:2310 N 400 E STE A
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1796
Practice Address - Country:US
Practice Address - Phone:435-787-2000
Practice Address - Fax:435-787-1913
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12485839-1206363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT12485839-1206OtherLICENSE