Provider Demographics
NPI:1225644768
Name:SHORT, TASHA MARIE
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:MARIE
Last Name:SHORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 167
Mailing Address - Street 2:
Mailing Address - City:PREMIER
Mailing Address - State:WV
Mailing Address - Zip Code:24878-0167
Mailing Address - Country:US
Mailing Address - Phone:304-436-6635
Mailing Address - Fax:
Practice Address - Street 1:34 BUCKWHEAT RD
Practice Address - Street 2:
Practice Address - City:PREMIER
Practice Address - State:WV
Practice Address - Zip Code:24878
Practice Address - Country:US
Practice Address - Phone:304-436-6635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant