Provider Demographics
NPI:1659961845
Name:SPADE, TANNER (DPT)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:SPADE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 S DOUGLAS HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-4982
Mailing Address - Country:US
Mailing Address - Phone:307-670-9191
Mailing Address - Fax:
Practice Address - Street 1:1211 S DOUGLAS HWY STE 100
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-4982
Practice Address - Country:US
Practice Address - Phone:307-670-9191
Practice Address - Fax:307-670-9193
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-1715225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist