Provider Demographics
NPI:1881657245
Name:MATTISON, TANNER L (MD)
Entity Type:Individual
Prefix:DR
First Name:TANNER
Middle Name:L
Last Name:MATTISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-3035
Mailing Address - Country:US
Mailing Address - Phone:806-771-2018
Mailing Address - Fax:806-771-2078
Practice Address - Street 1:6221 RIVERSIDE DR
Practice Address - Street 2:SUITE 119
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-3541
Practice Address - Country:US
Practice Address - Phone:877-232-9924
Practice Address - Fax:806-232-9927
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2451207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAMD.202224Medicaid
AZ42717Medicaid
CODR.0049728Medicaid
NMMD2008-0818Medicaid
TXL2451Medicaid
NY49732-1Medicaid
NC2008-02044Medicaid
NY49732-1Medicaid
TX8F8178Medicare PIN