Provider Demographics
NPI:1528402997
Name:PASHA, TAYYAB
Entity Type:Individual
Prefix:
First Name:TAYYAB
Middle Name:
Last Name:PASHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 AVENUE F N
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77414-3167
Mailing Address - Country:US
Mailing Address - Phone:979-245-2008
Mailing Address - Fax:
Practice Address - Street 1:2112 REGIONAL MEDICAL DR STE 1315
Practice Address - Street 2:
Practice Address - City:WHARTON
Practice Address - State:TX
Practice Address - Zip Code:77488-1413
Practice Address - Country:US
Practice Address - Phone:979-245-2008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ8597208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX359984702Medicaid