Healthcare Provider Details

I. General information

NPI: 1447428537
Provider Name (Legal Business Name): GARY SCOTT TAGGART PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 09/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1373 E BOONE ST SUITE 3401
TAHLEQUAH OK
74464-3330
US

IV. Provider business mailing address

1373 E BOONE ST SUITE 3401
TAHLEQUAH OK
74464-3330
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-6848
  • Fax: 918-456-1150
Mailing address:
  • Phone: 918-456-6848
  • Fax: 918-456-1150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1743
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200204150 A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: