Provider Demographics
NPI:1013597608
Name:BRONDHAVER, TANNER PAUL (DO)
Entity type:Individual
Prefix:DR
First Name:TANNER
Middle Name:PAUL
Last Name:BRONDHAVER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:222 MEDICAL CIR
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-1179
Mailing Address - Country:US
Mailing Address - Phone:606-783-6455
Mailing Address - Fax:606-784-2767
Practice Address - Street 1:222 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1179
Practice Address - Country:US
Practice Address - Phone:606-783-6455
Practice Address - Fax:606-784-2767
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR5677207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine