Provider Demographics
NPI:1881932390
Name:TANNER, GORDON R
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:R
Last Name:TANNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 NE 53RD TER
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32609-2623
Mailing Address - Country:US
Mailing Address - Phone:352-381-3506
Mailing Address - Fax:
Practice Address - Street 1:6421 SW 13TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-5419
Practice Address - Country:US
Practice Address - Phone:352-378-7891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA12950172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist