Provider Demographics
NPI:1467678920
Name:TAYLOR, MARLENE BEATRICE (PA)
Entity Type:Individual
Prefix:MS
First Name:MARLENE
Middle Name:BEATRICE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3649 JOHNSON AVE # 3
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-1671
Mailing Address - Country:US
Mailing Address - Phone:718-601-4772
Mailing Address - Fax:
Practice Address - Street 1:1824 MADISON AVE FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-3832
Practice Address - Country:US
Practice Address - Phone:212-423-4532
Practice Address - Fax:212-423-4045
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001834363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001834OtherLICENSE