Provider Demographics
NPI:1902815426
Name:TANNER, VAN E (PA)
Entity Type:Individual
Prefix:
First Name:VAN
Middle Name:E
Last Name:TANNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:919-477-6900
Mailing Address - Fax:919-477-5081
Practice Address - Street 1:4411 BEN FRANKLIN BLVD.
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2147
Practice Address - Country:US
Practice Address - Phone:919-477-0047
Practice Address - Fax:919-477-6919
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC103093363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical