1700913472 NPI number — AMANDA R TAYLOR PA-C

Table of content: AMANDA R TAYLOR PA-C (NPI 1700913472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700913472 NPI number — AMANDA R TAYLOR PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAYLOR
Provider First Name:
AMANDA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLAUSEN
Provider Other First Name:
AMANDA
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700913472
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5191 FIRST COAST TECH PKWY
Provider Second Line Business Mailing Address:
3RD FLOOR
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32224-0609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-223-3321
Provider Business Mailing Address Fax Number:
904-223-2169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2349 VILLAGE SQUARE PKWY STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLEMING ISLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32003-4319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-223-3321
Provider Business Practice Location Address Fax Number:
904-223-2169
Provider Enumeration Date:
02/28/2007

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: 363A00000X , with the licence number:  PA1020 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA9112944 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000514238 . This is a "ANTHEM- CMA- CHILDREN'S ORTHPAEDICS OF LOUISVILLE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 710001496 . This is a "MEDICAID KY- CHILDREN'S ORTHOPAEDICS OF LOUISVILLE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2847841000 . This is a "PASSPORT ADVANTAGE- CHILDREN'S ORTHOPAEDICS OF LOUISVILLE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000051983D . This is a "HUMANA- NORTON CHILDREN'S ORTHOPAEDICS OF LOUISVILLE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7985259 . This is a "CIGNA- NORTON CHILDREN'S ORTHOPAEDICS OF LOUISVILLE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50015087 . This is a "PASSPORT- CHILDREN'S ORTHOPAEDICS OF LOUISVILLE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 611276316-046 . This is a "TRICARE- CHILDREN'S ORTHOPAEDICS OF LOUISVILLE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 110469400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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