Provider Demographics
NPI:1689776387
Name:TANNER, ANDY R (DO)
Entity Type:Individual
Prefix:DR
First Name:ANDY
Middle Name:R
Last Name:TANNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7000
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-7000
Mailing Address - Country:US
Mailing Address - Phone:304-347-1296
Mailing Address - Fax:304-347-1397
Practice Address - Street 1:1201 WASHINGTON ST E
Practice Address - Street 2:SUITE 108
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1834
Practice Address - Country:US
Practice Address - Phone:304-347-4600
Practice Address - Fax:304-347-4621
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1817207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1805842000Medicaid
WVTA4043077Medicare ID - Type Unspecified
WV1805842000Medicaid