Provider Demographics
NPI:1851472559
Name:CUSTER, TAYLOR (PT, DPT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:CUSTER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:
Other - Last Name:POMEROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2915 NORTH 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004
Mailing Address - Country:US
Mailing Address - Phone:928-779-1679
Mailing Address - Fax:928-779-2822
Practice Address - Street 1:2915 NORTH 4TH STREET
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004
Practice Address - Country:US
Practice Address - Phone:928-779-1679
Practice Address - Fax:928-779-2822
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7317225100000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ137175OtherAHCCCS #