Provider Demographics
NPI:1851529598
Name:TANNER, TYSON R (OD)
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:R
Last Name:TANNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:545 S BROADWAY
Mailing Address - Street 2:SUITE #500
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-4067
Mailing Address - Country:US
Mailing Address - Phone:720-570-0660
Mailing Address - Fax:720-570-3223
Practice Address - Street 1:1938 S DOBSON RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-5658
Practice Address - Country:US
Practice Address - Phone:480-777-1649
Practice Address - Fax:480-894-2054
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1690152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist