Provider Demographics
NPI:1033375191
Name:APPEL-BASHAM, CAROL (PA)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:APPEL-BASHAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:COVELO
Mailing Address - State:CA
Mailing Address - Zip Code:95428-0247
Mailing Address - Country:US
Mailing Address - Phone:707-983-6181
Mailing Address - Fax:707-983-6802
Practice Address - Street 1:HWY 162 AND BIGGAR LANE
Practice Address - Street 2:
Practice Address - City:COVELO
Practice Address - State:CA
Practice Address - Zip Code:95428
Practice Address - Country:US
Practice Address - Phone:707-983-6181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11245363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1730237116Medicaid
CA1275710006Medicaid