Provider Demographics
NPI:1003908195
Name:TAYLOR, JASON LAMAR (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LAMAR
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2802 CIMARRON DR
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-7806
Mailing Address - Country:US
Mailing Address - Phone:928-757-7510
Mailing Address - Fax:
Practice Address - Street 1:1501 N WILLIAMSON AVE
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-2735
Practice Address - Country:US
Practice Address - Phone:928-289-4691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4184207P00000X
NV1364207P00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV105516Medicare PIN
NVAT600ZMedicare PIN