Provider Demographics
NPI:1891479929
Name:BAUCOM, TAYLOR KEITH (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TAYLOR
Middle Name:KEITH
Last Name:BAUCOM
Suffix:
Gender:M
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 1:4917 CAMPOBELLO DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110
Mailing Address - Country:US
Mailing Address - Phone:704-221-6042
Mailing Address - Fax:
Practice Address - Street 1:3793 MCDOWELL LN
Practice Address - Street 2:MEDICAL PARK 2, SUITE 100
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566
Practice Address - Country:US
Practice Address - Phone:843-390-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4861363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant