Provider Demographics
NPI:1891328712
Name:TANNER, DWAYNE L
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:L
Last Name:TANNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 GAIL AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-2610
Mailing Address - Country:US
Mailing Address - Phone:229-288-7649
Mailing Address - Fax:
Practice Address - Street 1:1120 W BROAD AVE STE B2
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-4385
Practice Address - Country:US
Practice Address - Phone:229-288-7649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker