Provider Demographics
NPI:1750086419
Name:NIELSON, TANNER COLE (MD)
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:COLE
Last Name:NIELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18575 OLD HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:SAUCIER
Mailing Address - State:MS
Mailing Address - Zip Code:39574-8419
Mailing Address - Country:US
Mailing Address - Phone:228-243-9630
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:018-156-7006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1750086419207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine