Basic Information
| Provider Information | |||||||||
| NPI: | 1336617349 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | JOHNATHAN | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DNP, APRN, NP-C, CEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9523 26TH BAY ST | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235181813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109958219 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 576 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | FORT EUSTIS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236041373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573147654 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2018 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024176672 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.