Basic Information
| Provider Information | |||||||||
| NPI: | 1043275241 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 ILLINOIS AVE | ||||||||
| Address2: | |||||||||
| City: | STEVENS POINT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544813114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153465000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 900 ILLINOIS AVE | ||||||||
| Address2: | |||||||||
| City: | STEVENS POINT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544813114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153465000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 06/07/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0200X | 132736-030 | WI | N | Nursing Service Providers | Registered Nurse | Critical Care Medicine | 367500000X | 3375 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3375 | 01 | WI | WI STATE LICENSE | OTHER | 132736-30 | 01 | WI | RN WI STATE LICENSE | OTHER |