Healthcare Provider Details

I. General information

NPI: 1093111304
Provider Name (Legal Business Name): DEREK J. TAYLOR PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2014
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 E. PRESIDIO STREET #101
MESA AZ
85215-3031
US

IV. Provider business mailing address

5155 E. EAGLE DRIVE #20730
MESA AZ
85277-3031
US

V. Phone/Fax

Practice location:
  • Phone: 480-706-9430
  • Fax: 480-378-2273
Mailing address:
  • Phone: 480-706-9430
  • Fax: 480-378-2273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5941
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: