Provider Demographics
NPI:1518042654
Name:TAYLOR, KEVIN K (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:K
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 SPRING ARBOR RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-2748
Mailing Address - Country:US
Mailing Address - Phone:517-787-0500
Mailing Address - Fax:517-787-1555
Practice Address - Street 1:2424 SPRING ARBOR RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-2748
Practice Address - Country:US
Practice Address - Phone:517-787-0500
Practice Address - Fax:517-787-1555
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001125363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601001125OtherSTATE ID
MIC86046P01Medicare ID - Type Unspecified