1144306549 NPI number — JORDAN E TAYLOR PNP

Table of content: JORDAN E TAYLOR PNP (NPI 1144306549)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144306549 NPI number — JORDAN E TAYLOR PNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAYLOR
Provider First Name:
JORDAN
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MALLOY
Provider Other First Name:
JORDAN
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1144306549
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9425 N NEVADA ST STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99218-1286
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-270-0065
Provider Business Mailing Address Fax Number:
509-319-2520

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 W IRONWOOD DR
Provider Second Line Business Practice Location Address:
SUITE 155
Provider Business Practice Location Address City Name:
COEUR D ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83814-2656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-667-0585
Provider Business Practice Location Address Fax Number:
208-667-0876
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  NP729A , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: AP60904961 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NPXN3 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 9653353 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: NPXN2 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1047507 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: AP60904961 . This is a "ARNP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 000010153954 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1144306549 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 807343600 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: NP708ID , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010153955 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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