Provider Demographics
NPI:1578253001
Name:ANDERSON, TAYLA JO
Entity Type:Individual
Prefix:
First Name:TAYLA
Middle Name:JO
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 LOCUST AVE STE 4B
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-1435
Mailing Address - Country:US
Mailing Address - Phone:304-974-3297
Mailing Address - Fax:304-974-3299
Practice Address - Street 1:1325 LOCUST AVE STE 4B
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1435
Practice Address - Country:US
Practice Address - Phone:304-974-3297
Practice Address - Fax:304-974-3299
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2723363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant