Provider Demographics
NPI:1699204370
Name:GOODEN, TANNER JAMES (PTA)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:JAMES
Last Name:GOODEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 S HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-2077
Mailing Address - Country:US
Mailing Address - Phone:814-771-5619
Mailing Address - Fax:
Practice Address - Street 1:1901 HOWELL AVE
Practice Address - Street 2:
Practice Address - City:WORLAND
Practice Address - State:WY
Practice Address - Zip Code:82401-3733
Practice Address - Country:US
Practice Address - Phone:307-347-4285
Practice Address - Fax:307-347-2154
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE011221225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant