Provider Demographics
NPI:1912002536
Name:TAVENNER, THOMAS J (CRNA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:TAVENNER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 N 500 E
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84701-1917
Mailing Address - Country:US
Mailing Address - Phone:435-896-2934
Mailing Address - Fax:
Practice Address - Street 1:1000 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701-1857
Practice Address - Country:US
Practice Address - Phone:435-893-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT149511205797367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered