Provider Demographics
NPI:1508086075
Name:TANNER, DEANNA WADE (PA)
Entity Type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:WADE
Last Name:TANNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9920 INDEPENDENCE PARK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1487
Mailing Address - Country:US
Mailing Address - Phone:804-285-7420
Mailing Address - Fax:804-285-7454
Practice Address - Street 1:9920 INDEPENDENCE PARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-1487
Practice Address - Country:US
Practice Address - Phone:804-285-7420
Practice Address - Fax:804-285-7454
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002513363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1508088075Medicaid
VA10029494POtherOPTIMA/SENTARA
VA61459602OtherBLACK LUNG/FECA
VA10029494POtherOPTIMA/SENTARA
VAP00606600Medicare PIN