Provider Demographics
NPI:1588647853
Name:TAYLOR, GERALD ALLEN (PAC)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:ALLEN
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1510 24TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1304
Mailing Address - Country:US
Mailing Address - Phone:320-259-0208
Mailing Address - Fax:320-259-0715
Practice Address - Street 1:1510 24TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1304
Practice Address - Country:US
Practice Address - Phone:320-259-0208
Practice Address - Fax:320-259-0715
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN9274363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
F30716Medicare UPIN