Provider Demographics
NPI:1932249539
Name:TANNER, BOYD D (PAC)
Entity Type:Individual
Prefix:
First Name:BOYD
Middle Name:D
Last Name:TANNER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 N UNIVERSITY PKWY
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1509
Mailing Address - Country:US
Mailing Address - Phone:801-830-9486
Mailing Address - Fax:801-655-1890
Practice Address - Street 1:2230 N UNIVERSITY PKWY
Practice Address - Street 2:SUITE 1A
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1509
Practice Address - Country:US
Practice Address - Phone:801-830-9486
Practice Address - Fax:801-655-1890
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6316068-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant