Provider Demographics
NPI:1285626820
Name:BASHORE, ROBERTA
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:BASHORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 PINE HOLLOW RD
Mailing Address - Street 2:SUITE 4B
Mailing Address - City:MC KEES ROCKS
Mailing Address - State:PA
Mailing Address - Zip Code:15136-1516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 PINE HOLLOW RD
Practice Address - Street 2:SUITE 4B
Practice Address - City:MC KEES ROCKS
Practice Address - State:PA
Practice Address - Zip Code:15136-1516
Practice Address - Country:US
Practice Address - Phone:412-331-6503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD066214L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001860974Medicaid
PA050209HRMMedicare ID - Type Unspecified
PA001860974Medicaid