Healthcare Provider Details

I. General information

NPI: 1891496469
Provider Name (Legal Business Name): TAYLOR ANNE WEEDA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 COLLEGE DR
GALLUP NM
87301-5600
US

IV. Provider business mailing address

2111 COLLEGE DR
GALLUP NM
87301-5600
US

V. Phone/Fax

Practice location:
  • Phone: 505-397-5172
  • Fax: 877-396-1184
Mailing address:
  • Phone: 505-397-5172
  • Fax: 877-396-1184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: