Provider Demographics
NPI:1992313514
Name:HALVORSON, TAYLOR MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MARIE
Last Name:HALVORSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:M
Other - Last Name:JOHNSHOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:19020 LOVE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-6873
Mailing Address - Country:US
Mailing Address - Phone:218-232-6559
Mailing Address - Fax:
Practice Address - Street 1:2014 S 6TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-4529
Practice Address - Country:US
Practice Address - Phone:218-829-7812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant