1083197107 NPI number — JESSICA ANN TAYLOR PA-C

Table of content: JESSICA ANN TAYLOR PA-C (NPI 1083197107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083197107 NPI number — JESSICA ANN TAYLOR PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAYLOR
Provider First Name:
JESSICA
Provider Middle Name:
ANN
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083197107
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6656 DOBBIN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21045-5841
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-381-1330
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6656 DOBBIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21045-5841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-381-1330
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/13/2018

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:  0110-006704 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 9475 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: C06942 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0110-006704 . This is a "VIRGINIA BOARD OF MEDICINE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 9475 . This is a "GEORGIA COMPOSITE MEDICAL BOARD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: C06942 . This is a "MARYLAND BOARD OF PHYSICIANS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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