Provider Demographics
NPI:1881683829
Name:TANNER, KEVIN SCOTT (DPM)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:SCOTT
Last Name:TANNER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3359 CENTER POINT RD NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5568
Mailing Address - Country:US
Mailing Address - Phone:319-393-4343
Mailing Address - Fax:319-393-4464
Practice Address - Street 1:3359 CENTER POINT RD NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5568
Practice Address - Country:US
Practice Address - Phone:319-393-4343
Practice Address - Fax:319-393-4464
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00676213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1172692Medicaid
IA10373OtherWELLMARK PROVIDER NUMBER
IA10373OtherWELLMARK PROVIDER NUMBER
IAU72487Medicare UPIN