Provider Demographics
NPI:1528182730
Name:TAYLOR, JAMES RAY (PT)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:RAY
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:845 SOUTH MAIN STREET
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935
Mailing Address - Country:US
Mailing Address - Phone:920-322-0447
Mailing Address - Fax:920-322-1362
Practice Address - Street 1:845 SOUTH MAIN STREET
Practice Address - Street 2:SUITE 120
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935
Practice Address - Country:US
Practice Address - Phone:920-322-0447
Practice Address - Fax:920-322-1362
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5862225100000X
WI5862-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40308800Medicaid
WIQ00358Medicare UPIN