Provider Demographics
NPI:1043275241
Name:TAYLOR, GARY LEE (CRNA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-3114
Mailing Address - Country:US
Mailing Address - Phone:715-346-5000
Mailing Address - Fax:
Practice Address - Street 1:900 ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-3114
Practice Address - Country:US
Practice Address - Phone:715-346-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI132736-030163WC0200X
WI3375367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3375OtherWI STATE LICENSE
WI132736-30OtherRN WI STATE LICENSE
WI211790093Medicare PIN
WI022444155Medicare PIN
WI3375OtherWI STATE LICENSE
WIP00932708Medicare Oscar/Certification
WI002380264Medicare PIN