Provider Demographics
NPI:1750039624
Name:GROSSMAN, TAYLOR YAEL
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:YAEL
Last Name:GROSSMAN
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 1:23633 BLYTHE ST
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91304-5802
Mailing Address - Country:US
Mailing Address - Phone:818-825-0916
Mailing Address - Fax:
Practice Address - Street 1:1310 CLUB DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94592-1187
Practice Address - Country:US
Practice Address - Phone:707-638-5809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
5874OtherHEALTH PARTNERS
568946544OtherBCBS