Provider Demographics
NPI:1598713083
Name:TAYLOR, MITCHELL D (PA-C)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:D
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 NW 53RD ST STE 102
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-6354
Mailing Address - Country:US
Mailing Address - Phone:866-816-7846
Mailing Address - Fax:954-458-2928
Practice Address - Street 1:6001 VINELAND RD STE 116
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-7829
Practice Address - Country:US
Practice Address - Phone:866-816-7846
Practice Address - Fax:954-458-2928
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103007363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDA5786OtherRAILROAD MEDICARE GROUP NUMBER
FL1497748743OtherGROUP NPI NUMBER / LRHSI
FL1497748743OtherGROUP NPI NUMBER / LRHSI
P94358Medicare UPIN