Provider Demographics
NPI:1831407147
Name:TANNER, BRAD (PA)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:TANNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5444 SOUTH GREEN STREET
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123
Mailing Address - Country:US
Mailing Address - Phone:801-284-1702
Mailing Address - Fax:801-262-3897
Practice Address - Street 1:5323 WOODROW ST STE 102
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5853
Practice Address - Country:US
Practice Address - Phone:801-913-1010
Practice Address - Fax:801-262-3897
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7777106-12062086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery