1619454428 NPI number — MISS STACIE KARENE TAYLOR PA-C

Table of content: MISS STACIE KARENE TAYLOR PA-C (NPI 1619454428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619454428 NPI number — MISS STACIE KARENE TAYLOR PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAYLOR
Provider First Name:
STACIE
Provider Middle Name:
KARENE
Provider Name Prefix Text:
MISS
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:
1619454428
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
405 SANIBELLE CIR UNIT 28
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHULA VISTA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91910-7546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-405-4222
Provider Business Mailing Address Fax Number:
619-671-6555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
446 ALTA RD STE 6100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92158-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-671-6546
Provider Business Practice Location Address Fax Number:
671-671-6555
Provider Enumeration Date:
07/24/2018

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: 363AM0700X , with the licence number:  PA14581 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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