Provider Demographics
NPI:1184011850
Name:CORUM, TASHUA
Entity type:Individual
Prefix:
First Name:TASHUA
Middle Name:
Last Name:CORUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TASHUA
Other - Middle Name:
Other - Last Name:CLEMMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3200 ADELINE ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-2407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3200 ADELINE ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703-2407
Practice Address - Country:US
Practice Address - Phone:510-601-0203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist