Provider Demographics
NPI:1205458874
Name:NOTTKE, TAYLOR CONROY (DO)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:CONROY
Last Name:NOTTKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1964 62ND ST
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:WI
Mailing Address - Zip Code:54025-6926
Mailing Address - Country:US
Mailing Address - Phone:612-345-2899
Mailing Address - Fax:
Practice Address - Street 1:1500 CURVE CREST BLVD W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6040
Practice Address - Country:US
Practice Address - Phone:651-439-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-17
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI81136-21208000000X
MN73652208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics