Provider Demographics
NPI:1750853693
Name:IAGO, TAYLOR DIANE (PA-C)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:DIANE
Last Name:IAGO
Suffix:
Gender:F
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 1:5300 N INDEPENDENCE AVE STE 280
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5555
Mailing Address - Country:US
Mailing Address - Phone:405-717-5496
Mailing Address - Fax:405-717-5499
Practice Address - Street 1:1205 HEALTH CENTER PKWY STE 240
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-6396
Practice Address - Country:US
Practice Address - Phone:405-717-5496
Practice Address - Fax:405-717-5499
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2963363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant