Basic Information
| Provider Information | |||||||||
| NPI: | 1467611137 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | DARIUS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 367 S. GULPH RD | ||||||||
| Address2: | ATT IPM CREDENTIALING | ||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194063121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753569393 | ||||||||
| FaxNumber: | 7753565590 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 2ND ST E | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342081042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417465111 | ||||||||
| FaxNumber: | 9417457233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 363A00000X | PA 9104223 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | Y06L6 | 01 | FL | BCBS | OTHER | 004309200 | 05 | FL | MEDICAID |