Provider Demographics
NPI:1447932538
Name:WILLSON, TAYLA JEAN (PA-C)
Entity type:Individual
Prefix:
First Name:TAYLA
Middle Name:JEAN
Last Name:WILLSON
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 1:345 BANK STREET
Mailing Address - Street 2:UNIT #1 REAR
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320
Mailing Address - Country:US
Mailing Address - Phone:860-287-1302
Mailing Address - Fax:
Practice Address - Street 1:365 MONTAUK AVENUE
Practice Address - Street 2:DEPARTMENT: SURGERY (INPATIENT)
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320
Practice Address - Country:US
Practice Address - Phone:860-442-0711
Practice Address - Fax:860-444-4709
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6218363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant