Provider Demographics
NPI:1346738010
Name:BASEBANG, SALOME MBOH
Entity Type:Individual
Prefix:
First Name:SALOME
Middle Name:MBOH
Last Name:BASEBANG
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 1:629 N TOWN EAST BLVD APT 120
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-8342
Mailing Address - Country:US
Mailing Address - Phone:214-325-0716
Mailing Address - Fax:
Practice Address - Street 1:629 N TOWN EAST BLVD APT 120
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-8342
Practice Address - Country:US
Practice Address - Phone:214-325-0716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-27
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX825443163W00000X
TXAP142942363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX24331856Medicaid