Provider Demographics
NPI:1083493050
Name:BASAS, RYAN CARTER
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:CARTER
Last Name:BASAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 WILLOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:BEN LOMOND
Mailing Address - State:CA
Mailing Address - Zip Code:95005-9714
Mailing Address - Country:US
Mailing Address - Phone:831-336-5196
Mailing Address - Fax:
Practice Address - Street 1:155 WILLOWBROOK DR
Practice Address - Street 2:
Practice Address - City:BEN LOMOND
Practice Address - State:CA
Practice Address - Zip Code:95005-9714
Practice Address - Country:US
Practice Address - Phone:831-336-5196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty