=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831696962
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAYLOR GILLILAND LACKEY MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2018
-----------------------------------------------------
Last Update Date | 07/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3705 MEDICAL PKWY STE 320
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78705-1023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-454-1873
-----------------------------------------------------
Fax | 512-371-7098
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3705 MEDICAL PKWY STE 320
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78705-1023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-454-1873
-----------------------------------------------------
Fax | 512-371-7098
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | V0788
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | V0788
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------