Provider Demographics
NPI:1467724591
Name:BASHAM-LEEDY, MISTY (PA-C)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:BASHAM-LEEDY
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:1906 BELLEVIEW AVENUE
Mailing Address - Street 2:CARILION RMH - DEPARTMENT OF EMERGENCY MEDICINE
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014
Mailing Address - Country:US
Mailing Address - Phone:540-266-6331
Mailing Address - Fax:540-981-9550
Practice Address - Street 1:1906 BELLEVIEW AVE SE
Practice Address - Street 2:CARILION RMH - DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1838
Practice Address - Country:US
Practice Address - Phone:540-266-6331
Practice Address - Fax:540-981-9550
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-06
Last Update Date:2021-09-29
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Provider Licenses
StateLicense IDTaxonomies
VA0110003761363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant