Provider Demographics
NPI:1295573434
Name:VERMILYEA, TAYTUM RAE (PA-C)
Entity type:Individual
Prefix:
First Name:TAYTUM
Middle Name:RAE
Last Name:VERMILYEA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TAYTUM
Other - Middle Name:RAE
Other - Last Name:MIKKELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3552 W BASELINE RD STE 240
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-3042
Mailing Address - Country:US
Mailing Address - Phone:928-404-1488
Mailing Address - Fax:866-232-8550
Practice Address - Street 1:3552 W BASELINE RD STE 240
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-3042
Practice Address - Country:US
Practice Address - Phone:602-635-6941
Practice Address - Fax:602-635-6952
Is Sole Proprietor?:No
Enumeration Date:2024-07-19
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10488363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant