Healthcare Provider Details

I. General information

NPI: 1619717782
Provider Name (Legal Business Name): TAYLOR RENEE BEARDT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TAYLOR RENEE HAAS

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S FREMONT AVE BLDG A-11
ALHAMBRA CA
91803-8800
US

IV. Provider business mailing address

4640 LA CRESCENTA AVE
LA CRESCENTA CA
91214-2916
US

V. Phone/Fax

Practice location:
  • Phone: 626-457-4240
  • Fax:
Mailing address:
  • Phone: 818-279-4620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number68604
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: