Healthcare Provider Details

I. General information

NPI: 1891708376
Provider Name (Legal Business Name): KENNETH RAY TAYLOR PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16300 ROSCOE BLVD
VAN NUYS CA
91406-1258
US

IV. Provider business mailing address

10630 SEPULVEDA BLVD STE 100
MISSION HILLS CA
91345-1937
US

V. Phone/Fax

Practice location:
  • Phone: 818-893-4426
  • Fax:
Mailing address:
  • Phone: 818-933-4440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-15549
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: