Provider Demographics
NPI:1760486328
Name:TANNER, KIRK W (CRNA)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:W
Last Name:TANNER
Suffix:
Gender:M
Credentials:CRNA
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 800778
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22908-0778
Mailing Address - Country:US
Mailing Address - Phone:434-982-4228
Mailing Address - Fax:434-924-2078
Practice Address - Street 1:1215 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0816
Practice Address - Country:US
Practice Address - Phone:434-924-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024094260367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008933481Medicaid
VA008933481Medicaid
VA430000784Medicare ID - Type Unspecified