Provider Demographics
NPI:1154865913
Name:REARDON, TAYLOR VICTORIA (PA C)
Entity type:Individual
Prefix:MS
First Name:TAYLOR
Middle Name:VICTORIA
Last Name:REARDON
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:PO BOX 1025
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14240-1025
Mailing Address - Country:US
Mailing Address - Phone:315-423-9722
Mailing Address - Fax:
Practice Address - Street 1:935 JAMES ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2502
Practice Address - Country:US
Practice Address - Phone:315-422-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-14
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54082363A00000X
NY021987363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant