Provider Demographics
NPI:1124743836
Name:HONNOLL, TAYLOR (PA-C)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:HONNOLL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 SPRING CT
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-7205
Mailing Address - Country:US
Mailing Address - Phone:209-814-4659
Mailing Address - Fax:
Practice Address - Street 1:1205 E NORTH ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4932
Practice Address - Country:US
Practice Address - Phone:209-814-4659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA61667363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant