MEDICARE: TAYLOR HEATH

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	0010-08505	NC

General Provider Information

NPI Number	:	1255816450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAYLOR HEATH

Provider Business Mailing Address
First Line	:	8203 PENUCHE WAY
Second Line	:
City	:	HOLLY SPRINGS
State	:	NC
Zip	:	27540-3378
Country	:	US
Telephone Number	:	320-282-4402
Fax Number	:

Provider Business Practice Location Address
First Line	:	620 DR CALVIN JONES HWY # 212
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-3100
Country	:	US
Telephone Number	:	919-761-5678
Fax Number	:

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

Provider Enumeration Date	:	10/03/2018
Last Update Date	:	10/03/2018

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