Provider Demographics
NPI:1700015286
Name:TOLLETT, TANNER N (MD)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:N
Last Name:TOLLETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17503
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-0503
Mailing Address - Country:US
Mailing Address - Phone:719-687-9999
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:2350 MEADOWS BLVD
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80109-8405
Practice Address - Country:US
Practice Address - Phone:720-455-0655
Practice Address - Fax:720-455-0065
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0051753208M00000X
CO51753207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO65832221Medicaid
CO65832221Medicaid