Provider Demographics
NPI:1811417264
Name:TAILLAC, VICTORIA (PA-C)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:TAILLAC
Suffix:
Gender:F
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 1:828 N EASTCAPITOL BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-2212
Mailing Address - Country:US
Mailing Address - Phone:801-699-8403
Mailing Address - Fax:
Practice Address - Street 1:5496 S 900 E
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84117-7204
Practice Address - Country:US
Practice Address - Phone:801-281-3223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
DCPA031370363A00000X
UT11909486-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant