Provider Demographics
NPI:1861565012
Name:BASSHAM, MARY E
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:BASSHAM
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 1:10827 KANE AVE
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90604-1825
Mailing Address - Country:US
Mailing Address - Phone:562-944-3162
Mailing Address - Fax:
Practice Address - Street 1:3130 S HARBOR BLVD
Practice Address - Street 2:250
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-6824
Practice Address - Country:US
Practice Address - Phone:714-619-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12387363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health