Provider Demographics
NPI:1144673237
Name:MOORE, TANNER MILES (DPM)
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:MILES
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 ROSE LN
Mailing Address - Street 2:
Mailing Address - City:WICKENBURG
Mailing Address - State:AZ
Mailing Address - Zip Code:85390-1448
Mailing Address - Country:US
Mailing Address - Phone:760-613-4402
Mailing Address - Fax:
Practice Address - Street 1:519 ROSE LN
Practice Address - Street 2:
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390-1448
Practice Address - Country:US
Practice Address - Phone:602-675-0478
Practice Address - Fax:602-675-0479
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPOD-000936213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery