Provider Demographics
NPI:1063488633
Name:TAYLOR, ANTHONY KEITH (PA)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:KEITH
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:791 OAK STREET
Mailing Address - Street 2:
Mailing Address - City:HAPEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30354
Mailing Address - Country:US
Mailing Address - Phone:404-601-2000
Mailing Address - Fax:404-559-0257
Practice Address - Street 1:791 OAK STREET
Practice Address - Street 2:
Practice Address - City:HAPEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30354
Practice Address - Country:US
Practice Address - Phone:404-601-2000
Practice Address - Fax:404-559-0257
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2007-09-27
Deactivation Date:2006-03-07
Deactivation Code:
Reactivation Date:2007-09-27
Provider Licenses
StateLicense IDTaxonomies
GA004325363AM0700X
GA04325363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ44915Medicare UPIN
GA97WCGPBMedicare ID - Type Unspecified