Basic Information
| Provider Information | |||||||||
| NPI: | 1851529598 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TANNER | ||||||||
| FirstName: | TYSON | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 545 S BROADWAY | ||||||||
| Address2: | SUITE #500 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802094067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7205700660 | ||||||||
| FaxNumber: | 7205703223 | ||||||||
| Practice Location | |||||||||
| Address1: | 1938 S DOBSON RD | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852025658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807771649 | ||||||||
| FaxNumber: | 4808942054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2009 | ||||||||
| LastUpdateDate: | 07/01/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1690 | AZ | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.