Provider Demographics
NPI:1952758187
Name:BROUGHTON, TAYLOR J (PA-C)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:J
Last Name:BROUGHTON
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:PO BOX 1529
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:WA
Mailing Address - Zip Code:99006-1529
Mailing Address - Country:US
Mailing Address - Phone:509-276-5005
Mailing Address - Fax:509-276-7785
Practice Address - Street 1:905 E D ST
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:WA
Practice Address - Zip Code:99006-5167
Practice Address - Country:US
Practice Address - Phone:509-276-5005
Practice Address - Fax:509-276-7785
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60685606363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant