Provider Demographics
NPI:1881657245
Name:MATTISON, TANNER LAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:TANNER
Middle Name:LAYNE
Last Name:MATTISON
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 1:2609 SIR GAWAIN LN
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-5719
Mailing Address - Country:US
Mailing Address - Phone:214-392-5871
Mailing Address - Fax:
Practice Address - Street 1:2609 SIR GAWAIN LN
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75056-5719
Practice Address - Country:US
Practice Address - Phone:214-392-5871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2451207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODR.0049728Medicaid
LAMD.202224Medicaid
NC2008-02044Medicaid
AZ42717Medicaid
TXL2451Medicaid
NMMD2008-0818Medicaid
NY49732-1Medicaid
NY49732-1Medicaid
TX8F8178Medicare PIN