Healthcare Provider Details

I. General information

NPI: 1972016897
Provider Name (Legal Business Name): TAYLOR HADLEY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 11/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3403 S DELSEA DR
VINELAND NJ
08360-7449
US

IV. Provider business mailing address

333 N SHORE RD
MARMORA NJ
08223-1601
US

V. Phone/Fax

Practice location:
  • Phone: 856-293-6974
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00453700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: