Provider Demographics
NPI:1669982740
Name:CARLSON, TANNER BO (PA-C)
Entity type:Individual
Prefix:MR
First Name:TANNER
Middle Name:BO
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:PO BOX 1641
Mailing Address - Street 2:
Mailing Address - City:GLOBE
Mailing Address - State:AZ
Mailing Address - Zip Code:85502-1641
Mailing Address - Country:US
Mailing Address - Phone:928-425-8200
Mailing Address - Fax:928-425-8406
Practice Address - Street 1:1100 E MONROE ST STE 101
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-1304
Practice Address - Country:US
Practice Address - Phone:928-425-8200
Practice Address - Fax:928-425-8406
Is Sole Proprietor?:No
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ6896363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical