Provider Demographics
NPI:1528629227
Name:TAYLOR, AMANDA NICOLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:NICOLE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:NICOLE
Other - Last Name:CAWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:P.O. BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8450
Mailing Address - Fax:
Practice Address - Street 1:5751 EDWARDS RANCH RD STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4120
Practice Address - Country:US
Practice Address - Phone:817-332-8848
Practice Address - Fax:817-335-2670
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12858363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant