Provider Demographics
NPI:1669943890
Name:D'ETCHEVERRY, TAYLOR ERIN (PA-C)
Entity type:Individual
Prefix:MS
First Name:TAYLOR
Middle Name:ERIN
Last Name:D'ETCHEVERRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:TAYLOR
Other - Middle Name:E
Other - Last Name:D'ETCHEVERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3100 MACCORKLE AVE SE STE 101
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1215
Mailing Address - Country:US
Mailing Address - Phone:304-388-5395
Mailing Address - Fax:
Practice Address - Street 1:3100 MACCORKLE AVE SE STE 101
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1215
Practice Address - Country:US
Practice Address - Phone:304-388-5395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22682086S0102X
390200000X
VA0110009282363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program