Provider Demographics
NPI:1568920601
Name:TAYCHER, GREGORY JON
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:JON
Last Name:TAYCHER
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 1:311 W NORTH WATER ST
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2647
Mailing Address - Country:US
Mailing Address - Phone:920-268-9675
Mailing Address - Fax:
Practice Address - Street 1:9701 W HIGGINS RD # 270
Practice Address - Street 2:
Practice Address - City:ROSEMONT
Practice Address - State:IL
Practice Address - Zip Code:60018-4703
Practice Address - Country:US
Practice Address - Phone:815-654-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085006962363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program