Provider Demographics
NPI:1679341754
Name:BANASZAK, TAYLOR MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MARIE
Last Name:BANASZAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:425 W COLONIAL DR STE 303
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-6863
Mailing Address - Country:US
Mailing Address - Phone:321-332-6947
Mailing Address - Fax:407-286-4515
Practice Address - Street 1:550 POPE AVE NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4679
Practice Address - Country:US
Practice Address - Phone:863-299-2630
Practice Address - Fax:863-904-0398
Is Sole Proprietor?:No
Enumeration Date:2023-12-18
Last Update Date:2024-10-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY030381363A00000X
FLPA9118109363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant