Healthcare Provider Details

I. General information

NPI: 1326063413
Provider Name (Legal Business Name): BRANDON C TAYLOR CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S 13TH ST
PEKIN IL
61554-4936
US

IV. Provider business mailing address

24537 E OAK PARK RD
CANTON IL
61520-8956
US

V. Phone/Fax

Practice location:
  • Phone: 309-353-0406
  • Fax: 309-347-1240
Mailing address:
  • Phone: 309-369-5422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: