Provider Demographics
NPI:1285250944
Name:TAJA, KEINAN
Entity type:Individual
Prefix:DR
First Name:KEINAN
Middle Name:
Last Name:TAJA
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 1:6078 FOUNTAIN POINTE APT 3
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-7625
Mailing Address - Country:US
Mailing Address - Phone:567-204-6035
Mailing Address - Fax:
Practice Address - Street 1:2 HURLEY PLZ STE 212
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5905
Practice Address - Country:US
Practice Address - Phone:810-262-9080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351046170390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program