MEDICARE: CHARLENE GWEN TAYLOR PA-C

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	363AM0700X	Medical Physician Assistant
2	363A00000X	Physician Assistant	CO 1990	CO

General Provider Information

NPI Number	:	1285614990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLENE GWEN TAYLOR PA-C

Provider Business Mailing Address
First Line	:	478 EL PASO BLVD
Second Line	:
City	:	MANITOU SPRINGS
State	:	CO
Zip	:	80829-2310
Country	:	US
Telephone Number	:
Fax Number	:	719-526-8883

Provider Business Practice Location Address
First Line	:	1852 OCONNELL BLVD
Second Line	:	BLDG 1042
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80913-4054
Country	:	US
Telephone Number	:	719-524-5280
Fax Number	:

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

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	04/23/2021

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