Healthcare Provider Details

I. General information

NPI: 1629734603
Provider Name (Legal Business Name): TAYLOR ELIZABETH GILLETTE DWYER ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2021
Last Update Date: 06/18/2022
Certification Date: 06/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 GENESEE ST STE 2
ONEIDA NY
13421-2658
US

IV. Provider business mailing address

9717 POWELL RD
HOLLAND PATENT NY
13354-4336
US

V. Phone/Fax

Practice location:
  • Phone: 518-409-2025
  • Fax:
Mailing address:
  • Phone: 518-409-2025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: