Healthcare Provider Details

I. General information

NPI: 1063488633
Provider Name (Legal Business Name): ANTHONY KEITH TAYLOR PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 09/27/2007
Certification Date:
Deactivation Date: 03/07/2006
Reactivation Date: 09/27/2007

III. Provider practice location address

791 OAK STREET
HAPEVILLE GA
30354
US

IV. Provider business mailing address

791 OAK STREET
HAPEVILLE GA
30354
US

V. Phone/Fax

Practice location:
  • Phone: 404-601-2000
  • Fax: 404-559-0257
Mailing address:
  • Phone: 404-601-2000
  • Fax: 404-559-0257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004325
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number04325
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: