Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | R983 | AZ |
NPI | 1003092842 |
---|---|
Provider Name | Michael Devin Taylor |
First Address | Phoenix, AZ 85013-4102 |
Second Address | Phoenix, AZ 85013-4102 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/01/2008 |
Last Update Date | 30/11/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
R983 | TRAINER PERMIT (01) | AZ |