Healthcare Provider Details

I. General information

NPI: 1629515614
Provider Name (Legal Business Name): JAMIE N TAYLOR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2017
Last Update Date: 12/30/2020
Certification Date: 12/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 LAKE ST
ROSCOMMON MI
48653-7658
US

IV. Provider business mailing address

9249 W LAKE CITY RD
HOUGHTON LAKE MI
48629-9602
US

V. Phone/Fax

Practice location:
  • Phone: 989-422-5122
  • Fax: 989-422-4378
Mailing address:
  • Phone: 989-422-5122
  • Fax: 989-422-4378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601008145
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: