Provider Demographics
NPI:1669004404
Name:TANNER, BRIANA NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIANA
Middle Name:NICOLE
Last Name:TANNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BRIANA
Other - Middle Name:NICOLE
Other - Last Name:OETMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3185 MACATAWA DR SW STE A
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-3184
Practice Address - Country:US
Practice Address - Phone:616-391-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010171363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant