Provider Demographics
NPI:1922486539
Name:TAYLOR, DWAYNE (NP)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3708 NORTHSIDE DR BLDG B
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2404
Mailing Address - Country:US
Mailing Address - Phone:478-633-6115
Mailing Address - Fax:478-633-1947
Practice Address - Street 1:3708 NORTHSIDE DR BLDG B
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2404
Practice Address - Country:US
Practice Address - Phone:478-633-6115
Practice Address - Fax:478-633-1947
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN201624363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN201624OtherGA NP LICENSE