Provider Demographics
NPI:1477089753
Name:TAYLOR, ANDRE (ATC)
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 PEBBLECREEK DR
Mailing Address - Street 2:APT. B
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-9502
Mailing Address - Country:US
Mailing Address - Phone:573-433-9069
Mailing Address - Fax:
Practice Address - Street 1:601 E 14TH ST
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-5972
Practice Address - Country:US
Practice Address - Phone:660-287-1225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160278572083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine