Provider Demographics
NPI:1295248805
Name:TANNER, EMILY SUZANNE (PA-C)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:SUZANNE
Last Name:TANNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7375 OSWEGO RD STE 1
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-3717
Mailing Address - Country:US
Mailing Address - Phone:315-291-0064
Mailing Address - Fax:
Practice Address - Street 1:7375 OSWEGO RD STE 1
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-3717
Practice Address - Country:US
Practice Address - Phone:315-291-0064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2023-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011450363A00000X
MDC06628363A00000X
NMPA2022-0126363A00000X
WA61021047363A00000X
OH50.007894RX363A00000X
IL085.009502363A00000X
PAMA064853363A00000X
FLPA9117452363A00000X
WI7390-23363A00000X
IN10004125A363A00000X
NY029170363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant