Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XX0004X | Foot and Ankle Orthopaedic Surgeon | 109070 | MN |
N | 207XX0004X | Foot and Ankle Orthopaedic Surgeon | 4301090393 | MI |
NPI | 1780882662 |
---|---|
Provider Name | John Clinton Tanner III |
First Address | Golden Valley, MN 55422-4840 |
Second Address | Robbinsdale, MN 55422-2948 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/07/2007 |
Last Update Date | 26/08/2016 |