Healthcare Provider Details

I. General information

NPI: 1437497849
Provider Name (Legal Business Name): WILLY TAYLOR PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2013
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 E SOUTH TEMPLE
SALT LAKE CITY UT
84102-1507
US

IV. Provider business mailing address

406 W SOUTH JORDAN PKWY STE 500
SOUTH JORDAN UT
84095-3945
US

V. Phone/Fax

Practice location:
  • Phone: 801-918-3380
  • Fax:
Mailing address:
  • Phone: 801-984-3218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number328698-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number328698-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: