Provider Demographics
NPI:1497793269
Name:TAYLOR, GREGORY G (CRNA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:G
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3810 WATERSIDE DR
Mailing Address - Street 2:#104
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-9738
Mailing Address - Country:US
Mailing Address - Phone:301-538-5352
Mailing Address - Fax:252-621-1003
Practice Address - Street 1:3810 WATERSIDE DR
Practice Address - Street 2:#104
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-9738
Practice Address - Country:US
Practice Address - Phone:301-538-5352
Practice Address - Fax:252-621-1003
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRO96528367500000X
NC158154367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD424601200Medicaid
MDS69056Medicare UPIN
MD491101Medicare ID - Type Unspecified