Provider Demographics
NPI:1285614990
Name:TAYLOR, CHARLENE GWEN (PA-C)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:GWEN
Last Name:TAYLOR
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 1:478 EL PASO BLVD
Mailing Address - Street 2:
Mailing Address - City:MANITOU SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80829-2310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:719-526-8883
Practice Address - Street 1:1852 OCONNELL BLVD
Practice Address - Street 2:BLDG 1042
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80913-4054
Practice Address - Country:US
Practice Address - Phone:719-524-5280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
COCO 1990363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical