Provider Demographics
NPI:1952766040
Name:TANNER, BRUCE
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
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 1:9068 ONEIDA RIVER PARK DR
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041-9625
Mailing Address - Country:US
Mailing Address - Phone:315-436-5699
Mailing Address - Fax:315-409-4156
Practice Address - Street 1:9068 ONEIDA RIVER PARK DR
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:NY
Practice Address - Zip Code:13041-9625
Practice Address - Country:US
Practice Address - Phone:315-436-5699
Practice Address - Fax:315-409-4156
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies