Provider Demographics
NPI:1063069466
Name:TAYLOR, WENDELL REGINALD JR
Entity type:Individual
Prefix:MR
First Name:WENDELL
Middle Name:REGINALD
Last Name:TAYLOR
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 73720
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-3720
Mailing Address - Country:US
Mailing Address - Phone:513-498-2626
Mailing Address - Fax:
Practice Address - Street 1:1101 NOBLE ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4924
Practice Address - Country:US
Practice Address - Phone:907-458-2682
Practice Address - Fax:907-458-2628
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK234580363LF0000X
OH025228363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1756188Medicaid