Provider Demographics
NPI:1801671862
Name:KOON, TANNER ELIJAH (NP)
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:ELIJAH
Last Name:KOON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 PLAZA CIR STE J
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325-7559
Mailing Address - Country:US
Mailing Address - Phone:864-681-0555
Mailing Address - Fax:864-408-8675
Practice Address - Street 1:500 PLAZA CIR STE J
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-7559
Practice Address - Country:US
Practice Address - Phone:864-681-0555
Practice Address - Fax:864-408-8675
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27805363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily