Provider Demographics
NPI:1659628808
Name:TAYLOR, JOHN R
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 N 11TH ST
Mailing Address - Street 2:STE P3600
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1515
Mailing Address - Country:US
Mailing Address - Phone:409-724-7389
Mailing Address - Fax:
Practice Address - Street 1:2555 JIMMY JOHNSON BLVD
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640-2007
Practice Address - Country:US
Practice Address - Phone:409-724-7389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX818480367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered