=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265191852
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAYLOR MACKENZIE STANG PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2021
-----------------------------------------------------
Last Update Date | 12/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 N MAIN ST STE 100
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45402-3718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-499-8747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6989 CHESTNUT OAK CT
-----------------------------------------------------
City | FAIRFIELD TOWNSHIP
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45011-5683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 50.007155RX
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------