Provider Demographics
NPI:1861549396
Name:BASEN, GRETCHEN G (PA-C)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:G
Last Name:BASEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-928-7773
Mailing Address - Fax:
Practice Address - Street 1:775 POLE LINE RD W
Practice Address - Street 2:SUITE 115
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5814
Practice Address - Country:US
Practice Address - Phone:208-814-8150
Practice Address - Fax:208-732-3112
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001509363AS0400X
IDPA-914363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1861549396Medicaid
MD174166Y1KMedicare PIN