Basic Information
Provider Information | |||||||||
NPI: | 1942787049 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCWILLIAMS | ||||||||
FirstName: | TAYLOR | ||||||||
MiddleName: | JON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 18872 YARBOROUGH TRCE | ||||||||
Address2: |   | ||||||||
City: | MAPLE GROVE | ||||||||
State: | MN | ||||||||
PostalCode: | 553111156 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7635167889 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 800 PRAIRIE CENTER DR STE 230 | ||||||||
Address2: |   | ||||||||
City: | EDEN PRAIRIE | ||||||||
State: | MN | ||||||||
PostalCode: | 553447308 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9529445314 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/23/2018 | ||||||||
LastUpdateDate: | 07/23/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251S0007X | 11139 | MN | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports |
No ID Information.