Provider Demographics
NPI:1558012872
Name:VANSANDT, TAYLOR (PA-C)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:VANSANDT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:
Other - Last Name:GODFREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:165 WENDELL COURT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1825 HWY 34 E STE 1200
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-3892
Practice Address - Country:US
Practice Address - Phone:770-502-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-18
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11539OtherGA STATE LICENSE