Provider Demographics
NPI:1649042151
Name:PAYNE, TANNER MURPHY
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:MURPHY
Last Name:PAYNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9756 COUNTY ROAD 373
Mailing Address - Street 2:
Mailing Address - City:NEW BLOOMFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65063-2701
Mailing Address - Country:US
Mailing Address - Phone:573-826-5306
Mailing Address - Fax:
Practice Address - Street 1:1 VETERANS DR.
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265
Practice Address - Country:US
Practice Address - Phone:573-581-1088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023042164224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant