Provider Demographics
NPI:1639387798
Name:TAYLOR, COURTNEY N (PA-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:N
Last Name:TAYLOR
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 1:24 FRANK LLOYD WRIGHT DR LBBY J2000
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:
Practice Address - Street 1:4350 JACKSON RD STE 200
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-1889
Practice Address - Country:US
Practice Address - Phone:734-761-2581
Practice Address - Fax:734-761-9540
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004237363AM0700X
MI5601008922363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ18453Medicare UPIN
GA97WCFNDMedicare ID - Type Unspecified