Healthcare Provider Details

I. General information

NPI: 1366773376
Provider Name (Legal Business Name): JEFFERY GRANT TAYLOR MPAS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1086 JAYLEE DR UNIT 1
RIGBY ID
83442-4983
US

IV. Provider business mailing address

1086 JAYLEE DR UNIT 1
RIGBY ID
83442-4983
US

V. Phone/Fax

Practice location:
  • Phone: 719-352-5383
  • Fax: 907-205-5962
Mailing address:
  • Phone: 719-352-5383
  • Fax: 907-205-5962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number203148
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1091583
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-2639
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: