Provider Demographics
NPI:1063485316
Name:TAYLOR, MARILYN SUE (PA)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:SUE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 268838
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-8838
Mailing Address - Country:US
Mailing Address - Phone:918-660-3632
Mailing Address - Fax:918-660-3631
Practice Address - Street 1:9500 N 129TH EAST AVE
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-5378
Practice Address - Country:US
Practice Address - Phone:918-858-4353
Practice Address - Fax:866-246-2942
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2022-09-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK477363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100197730AMedicaid
P35812Medicare UPIN
OKPA00477Medicare ID - Type Unspecified