Provider Demographics
NPI:1659124931
Name:BONHAM, TANNER
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:BONHAM
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 1:8901 E ORME ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207-2473
Mailing Address - Country:US
Mailing Address - Phone:316-641-3548
Mailing Address - Fax:
Practice Address - Street 1:8901 E ORME ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-2473
Practice Address - Country:US
Practice Address - Phone:316-641-3548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician