Provider Demographics
NPI:1689692147
Name:TAYLOR, MICHAEL R (PA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:R
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8131
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-7200
Mailing Address - Fax:314-747-4189
Practice Address - Street 1:510 S KINGSHIGHWAY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1016
Practice Address - Country:US
Practice Address - Phone:314-362-7200
Practice Address - Fax:314-747-4189
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107682363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant