Provider Demographics
NPI:1902900103
Name:TAYLOR, KEVIN RALPH (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:RALPH
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-5257
Mailing Address - Country:US
Mailing Address - Phone:509-547-7704
Mailing Address - Fax:509-542-3059
Practice Address - Street 1:5304 ROAD 68
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-8078
Practice Address - Country:US
Practice Address - Phone:509-543-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00021376207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8616906Medicaid
WA8616906Medicaid
WAA07405Medicare UPIN