Provider Demographics
NPI:1821563354
Name:TANNER, MCKAYLA NOBLE (AA)
Entity Type:Individual
Prefix:
First Name:MCKAYLA
Middle Name:NOBLE
Last Name:TANNER
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2125
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-2125
Mailing Address - Country:US
Mailing Address - Phone:334-279-1450
Mailing Address - Fax:334-279-1660
Practice Address - Street 1:915 GORDON AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6614
Practice Address - Country:US
Practice Address - Phone:334-279-1450
Practice Address - Fax:334-279-1660
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
367H00000X
GA9068367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant