Provider Demographics
NPI:1447837166
Name:SOUZA, TANNER (DO)
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:SOUZA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1517
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-0410
Mailing Address - Country:US
Mailing Address - Phone:541-278-4332
Mailing Address - Fax:
Practice Address - Street 1:1130 W PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8780
Practice Address - Country:US
Practice Address - Phone:208-209-0288
Practice Address - Fax:208-209-0289
Is Sole Proprietor?:No
Enumeration Date:2021-03-27
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO3477208D00000X
ID0-1993207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice