Provider Demographics
NPI:1962948422
Name:TAYLOR, CHARLSIE THOMAS (PA-C)
Entity type:Individual
Prefix:
First Name:CHARLSIE
Middle Name:THOMAS
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHARLSIE
Other - Middle Name:A
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1240 JESSE JEWELL PKWY SE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3862
Mailing Address - Country:US
Mailing Address - Phone:770-536-9864
Mailing Address - Fax:770-297-5023
Practice Address - Street 1:1240 JESSE JEWELL PKWY SE
Practice Address - Street 2:SUITE 500
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3862
Practice Address - Country:US
Practice Address - Phone:770-536-9864
Practice Address - Fax:770-297-5023
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008235363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA008235OtherLICENSE