Basic Information
| Provider Information | |||||||||
| NPI: | 1871055921 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | WAYNETTE | ||||||||
| MiddleName: | LESLIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4000 | ||||||||
| Address2: | |||||||||
| City: | POLACCA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860424000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287376000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 435 N 5TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850042157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028272450 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2019 | ||||||||
| LastUpdateDate: | 06/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.