Provider Demographics
NPI:1730953233
Name:BASULTO, KARLA
Entity type:Individual
Prefix:
First Name:KARLA
Middle Name:
Last Name:BASULTO
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 1:316 FREDERICK DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-2619
Mailing Address - Country:US
Mailing Address - Phone:512-649-6125
Mailing Address - Fax:
Practice Address - Street 1:316 FREDERICK DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-2619
Practice Address - Country:US
Practice Address - Phone:512-649-6125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23-430246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant