Provider Demographics
NPI:1124735345
Name:CIRKS, TAYLOR
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:CIRKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 W MAIN ST APT 207
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3088
Mailing Address - Country:US
Mailing Address - Phone:302-528-9159
Mailing Address - Fax:
Practice Address - Street 1:540 UNION BLVD
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-3105
Practice Address - Country:US
Practice Address - Phone:631-669-2555
Practice Address - Fax:631-669-5787
Is Sole Proprietor?:No
Enumeration Date:2022-10-28
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310833363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health