Provider Demographics
NPI:1508969452
Name:BASA, NICOLE REYES (MD)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:REYES
Last Name:BASA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1410 MEDICAL PKWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-7464
Mailing Address - Country:US
Mailing Address - Phone:512-260-3444
Mailing Address - Fax:512-260-3555
Practice Address - Street 1:1410 MEDICAL PKWY
Practice Address - Street 2:SUITE 1
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-7464
Practice Address - Country:US
Practice Address - Phone:512-260-3444
Practice Address - Fax:512-260-3555
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7029208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AQ401OtherBCBS TX
TX190366801Medicaid
TX190366801Medicaid