Healthcare Provider Details

I. General information

NPI: 1669943890
Provider Name (Legal Business Name): TAYLOR ERIN D'ETCHEVERRY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. TAYLOR E D'ETCHEVERRY

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MACCORKLE AVE SE STE 101
CHARLESTON WV
25304-1215
US

IV. Provider business mailing address

3100 MACCORKLE AVE SE STE 101
CHARLESTON WV
25304-1215
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-5395
  • Fax:
Mailing address:
  • Phone: 304-388-5395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number2268
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110009282
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: