Healthcare Provider Details

I. General information

NPI: 1568898666
Provider Name (Legal Business Name): TIMOTHY C TAYLOR PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2013
Last Update Date: 09/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1174 W MICHIGAN AVE
MARSHALL MI
49068-1497
US

IV. Provider business mailing address

1174 W MICHIGAN AVE
MARSHALL MI
49068-1497
US

V. Phone/Fax

Practice location:
  • Phone: 269-781-9867
  • Fax: 269-781-9126
Mailing address:
  • Phone: 269-781-9867
  • Fax: 269-781-9126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006752
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: