Provider Demographics
NPI:1043770589
Name:BOGUE, TAYLOR MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MARIE
Last Name:BOGUE
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 1:2166 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-4700
Mailing Address - Country:US
Mailing Address - Phone:618-452-3301
Mailing Address - Fax:
Practice Address - Street 1:2166 MADISON AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4700
Practice Address - Country:US
Practice Address - Phone:618-452-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006994363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant