Provider Demographics
NPI:1629470992
Name:KIMBER, TANNER (ATC)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:KIMBER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10523 FIRST TIMBERLANE DR
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-4466
Mailing Address - Country:US
Mailing Address - Phone:952-201-8978
Mailing Address - Fax:
Practice Address - Street 1:8100 NORTHLAND DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-4800
Practice Address - Country:US
Practice Address - Phone:952-806-5693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2000017447207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine