Provider Demographics
NPI:1649918566
Name:BUIE, TANNER VAUGHN (MAT, LAT, ATC)
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:VAUGHN
Last Name:BUIE
Suffix:
Gender:M
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:562 CENTENNIAL PKWY APT 701
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-7182
Mailing Address - Country:US
Mailing Address - Phone:660-412-3879
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-593-8441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-20
Last Update Date:2024-06-27
Deactivation Date:2024-06-06
Deactivation Code:
Reactivation Date:2024-06-27
Provider Licenses
StateLicense IDTaxonomies
TXAT97352255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer