Individual
JAY B TANNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
OEG 000400
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0011040000003
—
PA
05
—
0011040000005
—
PA
01
—
410043623
PALMETTO GBA-RRMC
PA
Enumeration date
07/26/2005
Last updated
04/29/2020
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