Healthcare Provider Details

I. General information

NPI: 1619609476
Provider Name (Legal Business Name): NICHOLAS JORDAN TAYLOR PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 W DUNLAP AVE
PHOENIX AZ
85021-2800
US

IV. Provider business mailing address

5445 DTC PKWY STE 1130
GREENWOOD VILLAGE CO
80111-3038
US

V. Phone/Fax

Practice location:
  • Phone: 602-325-2024
  • Fax: 720-925-5897
Mailing address:
  • Phone: 720-749-5599
  • Fax: 720-925-5897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9915
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: