Provider Demographics
NPI:1972769909
Name:TANNER, ROBERTA (APRN-RX, FNP-C)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:APRN-RX, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 2 BOX 9608
Mailing Address - Street 2:
Mailing Address - City:KEAAU
Mailing Address - State:HI
Mailing Address - Zip Code:96749-9332
Mailing Address - Country:US
Mailing Address - Phone:808-542-2742
Mailing Address - Fax:
Practice Address - Street 1:450 KILAUEA AVE
Practice Address - Street 2:STE. 105 BAY CLINIC, INC.
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3089
Practice Address - Country:US
Practice Address - Phone:808-961-4071
Practice Address - Fax:808-961-5678
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-30
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRN-22282163W00000X
HI1427363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1972769909Medicare PIN