Provider Demographics
NPI:1598209512
Name:WESLEY, TAYLOR M (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:M
Last Name:WESLEY
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
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Mailing Address - Street 1:300 N MORLEY ST STE A-C
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-2334
Mailing Address - Country:US
Mailing Address - Phone:660-263-1225
Mailing Address - Fax:660-263-1613
Practice Address - Street 1:300 N MORLEY ST STE A-C
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-2334
Practice Address - Country:US
Practice Address - Phone:660-263-1225
Practice Address - Fax:660-263-1613
Is Sole Proprietor?:No
Enumeration Date:2016-12-09
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2016043086363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant