Provider Demographics
NPI:1083742787
Name:BASHAM, MATTHEW CLARK (MS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CLARK
Last Name:BASHAM
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 VIVIGEN WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505
Mailing Address - Country:US
Mailing Address - Phone:800-326-7002
Mailing Address - Fax:
Practice Address - Street 1:833 CHESTNUT ST # 1035
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4414
Practice Address - Country:US
Practice Address - Phone:888-816-3862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2002022170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS