Provider Demographics
NPI:1558697698
Name:TAYLOR, JUSTIN K (NMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:K
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:WA
Mailing Address - Zip Code:98541-9560
Mailing Address - Country:US
Mailing Address - Phone:360-346-2222
Mailing Address - Fax:
Practice Address - Street 1:600 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:WA
Practice Address - Zip Code:98541-9560
Practice Address - Country:US
Practice Address - Phone:360-346-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-25
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10-1178175F00000X
WANT60724012175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2074886Medicaid