Provider Demographics
NPI:1205030533
Name:TAYLOR, ANTHONY THEODORE (PA)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:THEODORE
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1642 E CYRENE DR
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-2928
Mailing Address - Country:US
Mailing Address - Phone:818-700-1250
Mailing Address - Fax:818-700-1045
Practice Address - Street 1:211 S MACLAY AVE
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-3603
Practice Address - Country:US
Practice Address - Phone:818-700-1250
Practice Address - Fax:818-700-1045
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10963363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMT0606840OtherDEA