Provider Demographics
NPI:1548367667
Name:TANNER, REBECCA WEBB
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:WEBB
Last Name:TANNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4582 FRANKLIN RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-5144
Mailing Address - Country:US
Mailing Address - Phone:540-772-8052
Mailing Address - Fax:540-772-4508
Practice Address - Street 1:4582 FRANKLIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-5144
Practice Address - Country:US
Practice Address - Phone:540-772-8052
Practice Address - Fax:540-772-4508
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101047618204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6801510Medicaid
VAF67749Medicare UPIN