Provider Demographics
NPI:1295839371
Name:TAYLOR, MARK S (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 TAYLORVIEW LN
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-8145
Mailing Address - Country:US
Mailing Address - Phone:208-535-0057
Mailing Address - Fax:
Practice Address - Street 1:3800 TAYLORVIEW LN
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-8145
Practice Address - Country:US
Practice Address - Phone:208-535-0057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID12052251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics