Provider Demographics
NPI:1659440493
Name:TAYLOR, SAMUEL (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
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:PO BOX 15133
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-0133
Mailing Address - Country:US
Mailing Address - Phone:919-477-5152
Mailing Address - Fax:919-477-5474
Practice Address - Street 1:2000 DAN PROCTOR DR
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3810
Practice Address - Country:US
Practice Address - Phone:912-576-6200
Practice Address - Fax:919-477-5474
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004815363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA01157773OtherAMERIGROUP
GA762697290BMedicaid
GA762697290BMedicaid
GAP00458587Medicare PIN
SC511I970131Medicare PIN