Provider Demographics
NPI:1316931108
Name:MESA-TAYLOR, ANGELA (PA C)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:MESA-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 1:900 S PINE ISLAND RD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3920
Mailing Address - Country:US
Mailing Address - Phone:954-341-0074
Mailing Address - Fax:954-345-3474
Practice Address - Street 1:9120A WILES RD
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33067-1993
Practice Address - Country:US
Practice Address - Phone:954-341-0074
Practice Address - Fax:954-345-3474
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102174363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292467600Medicaid
FLU1392ZMedicare ID - Type Unspecified
FL292467600Medicaid