Provider Demographics
NPI:1487018172
Name:SPEAKE, TANNER A (PA-C)
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:A
Last Name:SPEAKE
Suffix:
Gender:M
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 1:2660 SW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-2442
Mailing Address - Country:US
Mailing Address - Phone:785-270-8880
Mailing Address - Fax:
Practice Address - Street 1:2660 SW 3RD ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-2442
Practice Address - Country:US
Practice Address - Phone:785-270-8880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-08
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01901363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS068002399OtherMEDICARE PTAN