Provider Demographics
NPI:1407623077
Name:WIGNALL, TAYLOR M (PA-C)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:M
Last Name:WIGNALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:M
Other - Last Name:GIDEON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1650
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-7949
Mailing Address - Country:US
Mailing Address - Phone:219-921-1444
Mailing Address - Fax:
Practice Address - Street 1:833 W LINCOLN HWY STE 110
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375-1674
Practice Address - Country:US
Practice Address - Phone:219-921-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-05
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant