Provider Demographics
NPI:1093304552
Name:PAYNE, TAYLOR RUSSELL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TAYLOR
Middle Name:RUSSELL
Last Name:PAYNE
Suffix:
Gender:M
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 1:2837 W ANDREW JOHNSON HWY
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-3216
Mailing Address - Country:US
Mailing Address - Phone:423-353-1072
Mailing Address - Fax:
Practice Address - Street 1:2837 W ANDREW JOHNSON HWY
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3216
Practice Address - Country:US
Practice Address - Phone:423-353-1072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4362363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty