Provider Demographics
NPI:1700291648
Name:TANNER, SAVANNAH (PA-C)
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 PASEO DE PERALTA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1922
Mailing Address - Country:US
Mailing Address - Phone:505-989-8707
Mailing Address - Fax:505-989-3536
Practice Address - Street 1:707 PASEO DE PERALTA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1922
Practice Address - Country:US
Practice Address - Phone:505-989-8707
Practice Address - Fax:505-989-3536
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2014-0033363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant