Provider Demographics
NPI:1750667762
Name:TANNER, BRANDON DEE (PA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:DEE
Last Name:TANNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6856
Mailing Address - Country:US
Mailing Address - Phone:208-737-6718
Mailing Address - Fax:208-734-5036
Practice Address - Street 1:388 MARTIN ST
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4544
Practice Address - Country:US
Practice Address - Phone:208-734-0451
Practice Address - Fax:208-734-0452
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1058363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX865N24OtherBCBS TEXAS
TX289207701Medicaid
TX865N24OtherBCBS TEXAS