Basic Information
Provider Information | |||||||||
NPI: | 1821483389 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARMON | ||||||||
FirstName: | TANNER | ||||||||
MiddleName: | JESSE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1055 N 500 W | ||||||||
Address2: | ATTN CREDENTIALING | ||||||||
City: | PROVO | ||||||||
State: | UT | ||||||||
PostalCode: | 84604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013548225 | ||||||||
FaxNumber: | 8014180941 | ||||||||
Practice Location | |||||||||
Address1: | ATTN CREDENTIALING | ||||||||
Address2: | 1055 N 500 W | ||||||||
City: | PROVO | ||||||||
State: | UT | ||||||||
PostalCode: | 846048460 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013548225 | ||||||||
FaxNumber: | 8014180941 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/01/2015 | ||||||||
LastUpdateDate: | 04/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 33645 | NE | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 33645 | NE | N |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 2085R0202X | 12745075-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.