Provider Demographics
NPI:1962119503
Name:LANDIS, TAYLOR JANE (PA-C)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:JANE
Last Name:LANDIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 986513
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02298-6513
Mailing Address - Country:US
Mailing Address - Phone:910-219-8326
Mailing Address - Fax:
Practice Address - Street 1:114A MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6328
Practice Address - Country:US
Practice Address - Phone:910-353-0700
Practice Address - Fax:910-353-5305
Is Sole Proprietor?:No
Enumeration Date:2022-11-02
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-14619363AM0700X
PAMA064059363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical