Provider Demographics
NPI:1033189386
Name:TAYLOR, ROBERTA R (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:R
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9007 MOUNTAINBERRY CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-2343
Mailing Address - Country:US
Mailing Address - Phone:301-694-5435
Mailing Address - Fax:301-694-5435
Practice Address - Street 1:85 THOMAS JOHNSON CT
Practice Address - Street 2:SUITE B
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4359
Practice Address - Country:US
Practice Address - Phone:301-663-9440
Practice Address - Fax:301-663-4602
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0000139363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS6342Medicare UPIN
MD708WMedicare ID - Type UnspecifiedMEDICARE