Healthcare Provider Details

I. General information

NPI: 1497929830
Provider Name (Legal Business Name): SARA M TAYLOR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARA M KERSHISNIK PA-C

II. Dates (important events)

Enumeration Date: 04/16/2008
Last Update Date: 03/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 U.S. HWY 61 S
CRYSTAL CITY MO
63019
US

IV. Provider business mailing address

3902 CHERRY BROOK DR
ARNOLD MO
63010-5300
US

V. Phone/Fax

Practice location:
  • Phone: 636-933-1111
  • Fax:
Mailing address:
  • Phone: 701-793-0766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2008005001
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2008005001
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: