Basic Information
| Provider Information | |||||||||
| NPI: | 1487023263 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CALLINAN | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | JESSICA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751649 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437891620 | ||||||||
| FaxNumber: | 8437242440 | ||||||||
| Practice Location | |||||||||
| Address1: | 2145 HENRY TECKLENBURG DR STE 220 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294145894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437238823 | ||||||||
| FaxNumber: | 8436068059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2015 | ||||||||
| LastUpdateDate: | 01/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2407 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 2944PA | 05 | SC | MEDICAID |