Provider Demographics
NPI:1255666137
Name:BASKO, GRANT A
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:A
Last Name:BASKO
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:PO BOX 2400
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82902-2400
Mailing Address - Country:US
Mailing Address - Phone:307-362-4336
Mailing Address - Fax:307-362-4339
Practice Address - Street 1:820 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3342
Practice Address - Country:US
Practice Address - Phone:307-857-7074
Practice Address - Fax:307-856-6459
Is Sole Proprietor?:No
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOTR-763225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist