Provider Demographics
NPI:1740871060
Name:REDHEAD, TAHIRAH
Entity type:Individual
Prefix:
First Name:TAHIRAH
Middle Name:
Last Name:REDHEAD
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 1:100 WOODRUFF AVE APT 2C
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-1214
Mailing Address - Country:US
Mailing Address - Phone:718-208-9016
Mailing Address - Fax:
Practice Address - Street 1:1400 PELHAM PKWY S
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1197
Practice Address - Country:US
Practice Address - Phone:718-918-7052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant