Healthcare Provider Details

I. General information

NPI: 1063485316
Provider Name (Legal Business Name): MARILYN SUE TAYLOR PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 09/24/2022
Certification Date: 09/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 N 129TH EAST AVE
OWASSO OK
74055-5378
US

IV. Provider business mailing address

PO BOX 268838
OKLAHOMA CITY OK
73126-8838
US

V. Phone/Fax

Practice location:
  • Phone: 918-858-4353
  • Fax: 866-246-2942
Mailing address:
  • Phone: 918-660-3632
  • Fax: 918-660-3631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number477
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: