Provider Demographics
NPI:1932326873
Name:TANNER, MARK A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:TANNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:MARK
Other - Middle Name:A
Other - Last Name:TANNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4307 SENDERO DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-6321
Mailing Address - Country:US
Mailing Address - Phone:213-892-2257
Mailing Address - Fax:
Practice Address - Street 1:4201 BEE CAVE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-6465
Practice Address - Country:US
Practice Address - Phone:512-301-1712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00315363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical