Provider Demographics
NPI:1275839086
Name:TAYLOR, CHRYSTAL CLARICE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:CHRYSTAL
Middle Name:CLARICE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743752
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3752
Mailing Address - Country:US
Mailing Address - Phone:702-476-2800
Mailing Address - Fax:702-476-2040
Practice Address - Street 1:10652 S EASTERN AVE STE A
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4953
Practice Address - Country:US
Practice Address - Phone:702-476-2800
Practice Address - Fax:702-476-2040
Is Sole Proprietor?:No
Enumeration Date:2011-01-27
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1279363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant