Healthcare Provider Details

I. General information

NPI: 1932378213
Provider Name (Legal Business Name): GERALD TAYLOR JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2008
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MACCORKLE AVE SE, STE B16
CHARLESTON WV
25304
US

IV. Provider business mailing address

4605 MACCORKLE AVENUE, SW THS PHYSICIAN PARTNERS, INC.-ADMIN OFC
SOUTH CHARLESTON WV
25309
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-5848
  • Fax: 304-388-9654
Mailing address:
  • Phone: 304-414-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number01311
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1311
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: