Provider Demographics
NPI:1497905103
Name:TANNER, NATHAN SHAWN (DPT)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:SHAWN
Last Name:TANNER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 S POWER RD
Mailing Address - Street 2:#123
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-6686
Mailing Address - Country:US
Mailing Address - Phone:480-218-1344
Mailing Address - Fax:480-218-1356
Practice Address - Street 1:2500 S POWER RD
Practice Address - Street 2:#123
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-6686
Practice Address - Country:US
Practice Address - Phone:480-218-1344
Practice Address - Fax:480-218-1356
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8259225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist