Provider Demographics
NPI:1093476731
Name:PRIMAVERA, CAITLYN TAYLOR (PA)
Entity Type:Individual
Prefix:MS
First Name:CAITLYN
Middle Name:TAYLOR
Last Name:PRIMAVERA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3021 LYNNHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-1112
Mailing Address - Country:US
Mailing Address - Phone:850-896-7207
Mailing Address - Fax:
Practice Address - Street 1:3021 LYNNHAVEN DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-1112
Practice Address - Country:US
Practice Address - Phone:850-896-7207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0110009756363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program