Provider Demographics
NPI:1841010030
Name:WOLF, TANNER BRANCH (ATC, LAT, MS, BS)
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:BRANCH
Last Name:WOLF
Suffix:
Gender:M
Credentials:ATC, LAT, MS, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-6830
Mailing Address - Country:US
Mailing Address - Phone:605-222-7869
Mailing Address - Fax:
Practice Address - Street 1:2905 3RD AVE SE
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-5420
Practice Address - Country:US
Practice Address - Phone:605-626-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD05202255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer