Provider Demographics
NPI:1851115448
Name:TAYLOR, KEANDRE
Entity type:Individual
Prefix:
First Name:KEANDRE
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E GRUBB DR STE 109
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-3402
Mailing Address - Country:US
Mailing Address - Phone:972-285-6349
Mailing Address - Fax:
Practice Address - Street 1:125 E GRUBB DR STE 109
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-3402
Practice Address - Country:US
Practice Address - Phone:972-285-6349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-11
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1216468363A00000X
TXPA18760363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant