Healthcare Provider Details

I. General information

NPI: 1083354302
Provider Name (Legal Business Name): KASRA TALEB-HAGHIPOOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 05/07/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 UNION AVE 4 SHORB TOWER
MEMPHIS TN
38104
US

IV. Provider business mailing address

1211 UNION AVE STE 330
MEMPHIS TN
38104-6655
US

V. Phone/Fax

Practice location:
  • Phone: 901-478-9183
  • Fax: 901-478-8957
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5156
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: