Basic Information
Provider Information | |||||||||
NPI: | 1376992420 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TENNANT | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 20280 N 59TH AVE STE 115-317 | ||||||||
Address2: |   | ||||||||
City: | GLENDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853086850 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6027958710 | ||||||||
FaxNumber: | 6027958701 | ||||||||
Practice Location | |||||||||
Address1: | 7251 W 20TH ST UNIT K | ||||||||
Address2: |   | ||||||||
City: | GREELEY | ||||||||
State: | CO | ||||||||
PostalCode: | 806344626 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9704737900 | ||||||||
FaxNumber: | 9704737901 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2016 | ||||||||
LastUpdateDate: | 06/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | UO5342 | FL | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207LP2900X | 72454-21 | WI | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207LP2900X | DR.0066699 | CO | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 390200000X | TL0006255 | CO | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.