Provider Demographics
NPI:1649555939
Name:BASA, GRACIOUS K (FNP)
Entity type:Individual
Prefix:
First Name:GRACIOUS
Middle Name:K
Last Name:BASA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41670 IVY ST SUITE B
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-1707
Mailing Address - Country:US
Mailing Address - Phone:951-600-7702
Mailing Address - Fax:951-600-5987
Practice Address - Street 1:41670 IVY ST SUITE B
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-1707
Practice Address - Country:US
Practice Address - Phone:951-600-7702
Practice Address - Fax:951-600-5987
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-18
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20961363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily