Provider Demographics
NPI:1447428537
Name:TAGGART, GARY SCOTT (PA-C)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:SCOTT
Last Name:TAGGART
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1373 E BOONE ST
Mailing Address - Street 2:SUITE 3401
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3330
Mailing Address - Country:US
Mailing Address - Phone:918-456-6848
Mailing Address - Fax:918-456-1150
Practice Address - Street 1:1373 E BOONE ST
Practice Address - Street 2:SUITE 3401
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3330
Practice Address - Country:US
Practice Address - Phone:918-456-6848
Practice Address - Fax:918-456-1150
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1743363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200204150 AMedicaid
OKOK401486Medicare Oscar/Certification