Provider Demographics
NPI:1962017210
Name:CLOUGH, TAYLOR LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:LEE
Last Name:CLOUGH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:LEE
Other - Last Name:BOWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2760 WOODWIND WAY
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-4233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7911 MICHIGAN RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-1915
Practice Address - Country:US
Practice Address - Phone:317-956-6288
Practice Address - Fax:317-956-6289
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003012A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant