Basic Information
| Provider Information | |||||||||
| NPI: | 1093316184 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUMMERS | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | MACKENZIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 SUMMIT DR | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403519706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062074872 | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 BROOKS ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043881930 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2020 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 2931 | WV | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
No ID Information.