Provider Demographics
NPI:1326638883
Name:PAGE, TYESHA
Entity Type:Individual
Prefix:
First Name:TYESHA
Middle Name:
Last Name:PAGE
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 1:22421 BARTON RD # 288
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5008
Mailing Address - Country:US
Mailing Address - Phone:909-243-0473
Mailing Address - Fax:
Practice Address - Street 1:1267 WILLIS ST STE 200
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0400
Practice Address - Country:US
Practice Address - Phone:909-243-0473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)