Provider Demographics
NPI:1770053308
Name:TAYLOR, MICHEALA RENAE (GTA- DO STUDENT)
Entity type:Individual
Prefix:
First Name:MICHEALA
Middle Name:RENAE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:GTA- DO STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:
Practice Address - Street 1:3015 3RD AVE SE
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-5418
Practice Address - Country:US
Practice Address - Phone:605-226-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SD15511207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program