Individual
MR. TANNER JAMES VICK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1330 ROCKEFELLER AVE, STE 520, EVERETT, WA 98201-1684
(425) 297-5200
(425) 297-5210
Mailing address
PO BOX 3360, PROVIDENCE HEALTH & SERVICES, PORTLAND, OR 97208-3360
(866) 366-2983
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
PA10004747
WA
363AS0400X
Surgical Physician Assistant
Primary
PA10004747
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
191975
L&I PROVIDER NUMBER
WA
05
—
8412868
—
WA
Enumeration date
01/06/2006
Last updated
04/28/2021
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