Provider Demographics
NPI:1083932685
Name:BASHA, KATHLEEN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:BASHA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57392 M 51 S
Mailing Address - Street 2:
Mailing Address - City:DOWAGIAC
Mailing Address - State:MI
Mailing Address - Zip Code:49047-9766
Mailing Address - Country:US
Mailing Address - Phone:269-462-9587
Mailing Address - Fax:269-462-9589
Practice Address - Street 1:57392 M 51 S
Practice Address - Street 2:
Practice Address - City:DOWAGIAC
Practice Address - State:MI
Practice Address - Zip Code:49047-9766
Practice Address - Country:US
Practice Address - Phone:269-462-9587
Practice Address - Fax:269-462-9589
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005601363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI74575Medicaid
MI74575Medicaid
MIMB6124983OtherDEA