Provider Demographics
NPI:1275067506
Name:BASHUA, RALIAT OLUWAFUNKE
Entity Type:Individual
Prefix:DR
First Name:RALIAT
Middle Name:OLUWAFUNKE
Last Name:BASHUA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RALIAT
Other - Middle Name:
Other - Last Name:MOHAMMED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-273-8835
Mailing Address - Fax:717-202-0100
Practice Address - Street 1:845 HELEN DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7493
Practice Address - Country:US
Practice Address - Phone:717-273-8835
Practice Address - Fax:717-202-0100
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAFB0785040207V00000X
NY390200000X
PAMD475568207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY133971298OtherEIN