Provider Demographics
NPI:1033588504
Name:BEVAN, TAYLOR (FNP)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:BEVAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4504 BOAT CLUB RD STE 800
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-7002
Mailing Address - Country:US
Mailing Address - Phone:817-237-0515
Mailing Address - Fax:817-237-0611
Practice Address - Street 1:4504 BOAT CLUB RD STE 800
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-7002
Practice Address - Country:US
Practice Address - Phone:817-237-0515
Practice Address - Fax:817-237-0611
Is Sole Proprietor?:No
Enumeration Date:2015-09-15
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128451363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX449731YKPWMedicare PIN