Healthcare Provider Details

I. General information

NPI: 1629796701
Provider Name (Legal Business Name): MICHAEL TAYLOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 POLE CREEK XING STE 1
SIDNEY NE
69162-2902
US

IV. Provider business mailing address

900 CEDAR ST
JULESBURG CO
80737-1199
US

V. Phone/Fax

Practice location:
  • Phone: 308-254-5544
  • Fax: 308-254-2672
Mailing address:
  • Phone: 970-474-3323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0008904
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: