Provider Demographics
NPI:1073707501
Name:BASNYAT, SHRISTI (MD)
Entity Type:Individual
Prefix:
First Name:SHRISTI
Middle Name:
Last Name:BASNYAT
Suffix:
Gender:F
Credentials:MD
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 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9633
Mailing Address - Fax:239-343-4015
Practice Address - Street 1:3501 HEALTH CENTER BLVD STE 2220
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:34135-8129
Practice Address - Country:US
Practice Address - Phone:239-343-9633
Practice Address - Fax:239-343-4015
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
PAMD455033207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103694000Medicaid
NJ0468631Medicaid