Provider Demographics
NPI:1467238360
Name:BASILE, GRIFFIN KANE (PA-C)
Entity Type:Individual
Prefix:
First Name:GRIFFIN
Middle Name:KANE
Last Name:BASILE
Suffix:
Gender:M
Credentials:PA-C
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 1267
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-1267
Mailing Address - Country:US
Mailing Address - Phone:336-783-8911
Mailing Address - Fax:336-786-3752
Practice Address - Street 1:314 S SOUTH ST STE 100
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-4599
Practice Address - Country:US
Practice Address - Phone:336-718-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-13617363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty