Provider Demographics
NPI:1962586354
Name:HAIYEDE-SHITTU, TAYO E (DMSC, PA-C)
Entity type:Individual
Prefix:MRS
First Name:TAYO
Middle Name:E
Last Name:HAIYEDE-SHITTU
Suffix:
Gender:F
Credentials:DMSC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 530062
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-0062
Mailing Address - Country:US
Mailing Address - Phone:843-572-7727
Mailing Address - Fax:
Practice Address - Street 1:5500 FRONT ST STE 240
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-8140
Practice Address - Country:US
Practice Address - Phone:843-572-7727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011082363A00000X
SC1765363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1408PAMedicaid