Provider Demographics
NPI:1790012201
Name:TANNER, DUSTIN JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:JAMES
Last Name:TANNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 N PONCE DE LEON BLVD
Mailing Address - Street 2:SUITE #1
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-2600
Mailing Address - Country:US
Mailing Address - Phone:315-224-4042
Mailing Address - Fax:904-819-9310
Practice Address - Street 1:2200 N PONCE DE LEON BLVD
Practice Address - Street 2:SUITE #1
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-2600
Practice Address - Country:US
Practice Address - Phone:904-819-9110
Practice Address - Fax:904-819-9310
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 10578111N00000X
NYX012022-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJ300052763DMedicare UPIN