Provider Demographics
NPI:1396805529
Name:ANDERSON-TAYLOR, KRISTIN SUE (PA)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:SUE
Last Name:ANDERSON-TAYLOR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:SUE
Other - Last Name:ANDERSON-TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:TAYLOR
Mailing Address - Street 1:411 ORCHARD HILL RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30747-6548
Mailing Address - Country:US
Mailing Address - Phone:706-978-9991
Mailing Address - Fax:
Practice Address - Street 1:411 ORCHARD HILL RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:GA
Practice Address - Zip Code:30747-6548
Practice Address - Country:US
Practice Address - Phone:706-978-9991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002268363AM0700X
NY022313363AM0700X
GA6019363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1396805529Medicaid
GA1396805529Medicaid