Provider Demographics
NPI:1558910562
Name:TAYLOR, ANTWAHN MACK
Entity Type:Individual
Prefix:
First Name:ANTWAHN
Middle Name:MACK
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1644 RAVANUSA DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4071
Mailing Address - Country:US
Mailing Address - Phone:702-672-9117
Mailing Address - Fax:
Practice Address - Street 1:1644 RAVANUSA DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4071
Practice Address - Country:US
Practice Address - Phone:702-672-9117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner