MEDICARE: MS. CAITLYN TAYLOR PRIMAVERA PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA.0009814	CO
2	390200000X	Student in an Organized Health Care Education/Training Program
3	363A00000X	Physician Assistant	0110009756	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093476731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAITLYN TAYLOR PRIMAVERA PA

Provider Business Mailing Address
First Line	:	3021 LYNNHAVEN DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-1112
Country	:	US
Telephone Number	:	850-896-7207
Fax Number	:

Provider Business Practice Location Address
First Line	:	3021 LYNNHAVEN DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-1112
Country	:	US
Telephone Number	:	850-896-7207
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2022
Last Update Date	:	06/02/2026

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