Provider Demographics
NPI:1710573134
Name:WILSON, TAYLOR KETTLE (PA-C)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:KETTLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:ALEXANDRA
Other - Last Name:KETTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10601 CHURCH ST 105
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730
Mailing Address - Country:US
Mailing Address - Phone:909-989-7100
Mailing Address - Fax:909-989-6333
Practice Address - Street 1:10601 CHURCH ST 105
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:909-989-7100
Practice Address - Fax:909-989-6333
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-19
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program