Provider Demographics
NPI:1154512374
Name:TAYLOR, TARA LEIGH (PA-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LEIGH
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LEIGH
Other - Last Name:STROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6770 DIXIE HWY STE 314
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-5114
Mailing Address - Country:US
Mailing Address - Phone:248-762-5820
Mailing Address - Fax:888-375-2104
Practice Address - Street 1:6770 DIXIE HWY STE 314
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-5114
Practice Address - Country:US
Practice Address - Phone:248-762-5820
Practice Address - Fax:888-375-2104
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITT004211363AM0700X
MI5601004211363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MITT004211OtherSTATE LICENSE
MIQ08541Medicare UPIN