Provider Demographics
NPI:1932659620
Name:TAYLOR, JUSTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:TAYLOR
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 1:1470 N BROADWAY ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-1744
Mailing Address - Country:US
Mailing Address - Phone:513-932-1936
Mailing Address - Fax:513-932-3105
Practice Address - Street 1:1470 N BROADWAY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-1744
Practice Address - Country:US
Practice Address - Phone:513-932-1936
Practice Address - Fax:513-932-3105
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004858RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant