Provider Demographics
NPI:1356071328
Name:BASHAM, STEPHANIE MARIE (AGAC-NP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:BASHAM
Suffix:
Gender:F
Credentials:AGAC-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5715
Mailing Address - Fax:
Practice Address - Street 1:2001 CRYSTAL SPRING AVE SW STE 201
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-2465
Practice Address - Country:US
Practice Address - Phone:540-853-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024183788363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care