Provider Demographics
NPI:1639637507
Name:BRINSON, TAYLER
Entity Type:Individual
Prefix:
First Name:TAYLER
Middle Name:
Last Name:BRINSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6482 OLD LOUISVILLE RD
Mailing Address - Street 2:
Mailing Address - City:TARRYTOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30470-1704
Mailing Address - Country:US
Mailing Address - Phone:912-293-7582
Mailing Address - Fax:
Practice Address - Street 1:1430 JOHN WESLEY GILBERT DRIVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-1704
Practice Address - Country:US
Practice Address - Phone:706-723-4506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015901390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADN015901OtherDENTAL LICENSE
GAFB0006709OtherDEA LICENSE