Healthcare Provider Details

I. General information

NPI: 1750039624
Provider Name (Legal Business Name): TAYLOR YAEL GROSSMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2022
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 CLUB DR
VALLEJO CA
94592-1187
US

IV. Provider business mailing address

23633 BLYTHE ST
WEST HILLS CA
91304-5802
US

V. Phone/Fax

Practice location:
  • Phone: 707-638-5809
  • Fax:
Mailing address:
  • Phone: 818-825-0916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number64677
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: