Provider Demographics
NPI:1477889624
Name:BASCO, WILLIE T (PT)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:T
Last Name:BASCO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MARCUS HOOK
Mailing Address - State:PA
Mailing Address - Zip Code:19061-4513
Mailing Address - Country:US
Mailing Address - Phone:610-859-8850
Mailing Address - Fax:610-859-7876
Practice Address - Street 1:33 DEAK DR
Practice Address - Street 2:SUITE 101
Practice Address - City:SMYRNA
Practice Address - State:DE
Practice Address - Zip Code:19977-1268
Practice Address - Country:US
Practice Address - Phone:302-659-5700
Practice Address - Fax:302-659-5703
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10002517225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE000000020536OtherDPCI
DE1477889624Medicaid
DE3768331000OtherIBC
DE176795ZB8Medicare PIN