Provider Demographics
NPI:1700438546
Name:TAYLOR, GARY (PA-C)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 PLEASANT ST STE 204
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:NH
Mailing Address - Zip Code:03257-5881
Mailing Address - Country:US
Mailing Address - Phone:603-526-4635
Mailing Address - Fax:
Practice Address - Street 1:1200 WILLISTON RD
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-5720
Practice Address - Country:US
Practice Address - Phone:802-448-8205
Practice Address - Fax:802-448-8206
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09059363A00000X
VT055.0031517363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant