Provider Demographics
NPI:1649949561
Name:FREE, TANNER DAVID (DNP)
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:DAVID
Last Name:FREE
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4240 W 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1003
Practice Address - Country:US
Practice Address - Phone:305-243-4000
Practice Address - Fax:305-689-3593
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11023881363LF0000X
IN71011956A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001619023OtherANTHEM
IN300057259Medicaid
IN000001618766OtherANTHEM
IN000001618680OtherANTHEM