Provider Demographics
NPI:1497984033
Name:TANNER, TIFFANY NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:NICOLE
Last Name:TANNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988102 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:402-559-6195
Mailing Address - Fax:
Practice Address - Street 1:EMILE 42ND ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-1045
Practice Address - Country:US
Practice Address - Phone:402-559-9500
Practice Address - Fax:402-559-9560
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-02
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014015778208600000X
NE28503208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE28503OtherSTATE LICENSE
MO2014015778OtherLICENSE