Provider Demographics
NPI:1831652379
Name:COLVIN, TAYLOR GRANT (DO)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:GRANT
Last Name:COLVIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4011 TALBOT RD S STE 210
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-5791
Mailing Address - Country:US
Mailing Address - Phone:425-690-3602
Mailing Address - Fax:425-690-9602
Practice Address - Street 1:4011 TALBOT RD S STE 210
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5791
Practice Address - Country:US
Practice Address - Phone:425-690-3602
Practice Address - Fax:425-690-9602
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAOP61518044207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2292127Medicaid