Provider Demographics
NPI:1770685000
Name:TAYLOR, BRENT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2490 S WOODWORTH LOOP STE 400
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-7411
Mailing Address - Country:US
Mailing Address - Phone:907-745-9400
Mailing Address - Fax:907-745-9444
Practice Address - Street 1:2490 S WOODWORTH LOOP STE 400
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-7411
Practice Address - Country:US
Practice Address - Phone:907-745-9400
Practice Address - Fax:907-745-9444
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3517208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK11791Medicaid
AK11791Medicaid
AK152248Medicare ID - Type Unspecified