Provider Demographics
NPI:1619433547
Name:CARSON, TAYLOR RENEA (PA-C)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:RENEA
Last Name:CARSON
Suffix:
Gender:F
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 1:405 S OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:CHEROKEE
Mailing Address - State:OK
Mailing Address - Zip Code:73728-2545
Mailing Address - Country:US
Mailing Address - Phone:580-596-2800
Mailing Address - Fax:
Practice Address - Street 1:405 S OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:CHEROKEE
Practice Address - State:OK
Practice Address - Zip Code:73728-2545
Practice Address - Country:US
Practice Address - Phone:580-596-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3032363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant