Provider Demographics
NPI:1184188146
Name:ANDERSON, PAUL TAYLOR (MAT, LAT, ATC)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:TAYLOR
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11672 STOCKMEYER DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-0813
Mailing Address - Country:US
Mailing Address - Phone:915-252-3211
Mailing Address - Fax:
Practice Address - Street 1:11672 STOCKMEYER DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-0813
Practice Address - Country:US
Practice Address - Phone:915-252-3211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-24
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
TXAT78592255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer