Provider Demographics
NPI:1760731798
Name:TANNER, DANIEL D (NP)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:D
Last Name:TANNER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 WATER ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-2148
Mailing Address - Country:US
Mailing Address - Phone:574-237-9331
Mailing Address - Fax:574-237-9252
Practice Address - Street 1:105 WATER ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-2148
Practice Address - Country:US
Practice Address - Phone:574-237-9331
Practice Address - Fax:574-237-9252
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004120A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner