Basic Information
| Provider Information | |||||||||
| NPI: | 1093111304 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5155 E. EAGLE DRIVE #20730 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852773031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807069430 | ||||||||
| FaxNumber: | 4803782273 | ||||||||
| Practice Location | |||||||||
| Address1: | 4320 E. PRESIDIO STREET #101 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852153031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807069430 | ||||||||
| FaxNumber: | 4803782273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2014 | ||||||||
| LastUpdateDate: | 04/19/2018 | ||||||||
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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 | 363AS0400X | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 5941 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 983703 | 05 | AZ | MEDICAID |