Provider Demographics
NPI:1750862116
Name:ANDRE, TANNER WINN (PA)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:WINN
Last Name:ANDRE
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 1:19361 JASPER HILL RD
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-1185
Mailing Address - Country:US
Mailing Address - Phone:949-212-6116
Mailing Address - Fax:
Practice Address - Street 1:888 SWIFT BLVD
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3514
Practice Address - Country:US
Practice Address - Phone:949-212-6116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1151313207P00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine