Provider Demographics
NPI:1780205195
Name:ESTRADA, TAYLER
Entity Type:Individual
Prefix:
First Name:TAYLER
Middle Name:
Last Name:ESTRADA
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 1:113 NW YUKON TRAIL ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-5013
Mailing Address - Country:US
Mailing Address - Phone:479-899-3024
Mailing Address - Fax:
Practice Address - Street 1:113 NW YUKON TRAIL ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-5013
Practice Address - Country:US
Practice Address - Phone:479-899-3024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-27
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer