Provider Demographics
NPI:1265212104
Name:TANNER, MARY CRAWFORD (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CRAWFORD
Last Name:TANNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2630 E 7TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-4319
Mailing Address - Country:US
Mailing Address - Phone:704-364-6110
Mailing Address - Fax:704-364-4245
Practice Address - Street 1:2630 E 7TH ST STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-4319
Practice Address - Country:US
Practice Address - Phone:704-364-6110
Practice Address - Fax:704-364-4245
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC001013531363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical