Provider Demographics
NPI:1255852554
Name:DEJESUS, TAISHA
Entity Type:Individual
Prefix:MRS
First Name:TAISHA
Middle Name:
Last Name:DEJESUS
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 1:9008 GRIERS PASTURE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-0050
Mailing Address - Country:US
Mailing Address - Phone:518-331-4809
Mailing Address - Fax:
Practice Address - Street 1:9008 GRIERS PASTURE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28278-0050
Practice Address - Country:US
Practice Address - Phone:518-331-4809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04641416Medicaid