Provider Demographics
NPI:1588037329
Name:UNDERDAHL, TANNER LEE
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:LEE
Last Name:UNDERDAHL
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 1:100 WALL ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98121-1423
Mailing Address - Country:US
Mailing Address - Phone:651-247-0524
Mailing Address - Fax:
Practice Address - Street 1:100 WALL ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98121-1423
Practice Address - Country:US
Practice Address - Phone:651-247-0524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-02
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60594266111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor