Provider Demographics
NPI:1518144260
Name:BASHAM, SEVERINE MIA CLEMENCE (PA)
Entity Type:Individual
Prefix:MRS
First Name:SEVERINE
Middle Name:MIA CLEMENCE
Last Name:BASHAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:SEVY
Other - Middle Name:MIA CLEMENCE
Other - Last Name:BASHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:116 CONIFER RD
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-2958
Mailing Address - Country:US
Mailing Address - Phone:406-293-8711
Mailing Address - Fax:406-293-8735
Practice Address - Street 1:211 E 2ND ST
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-2047
Practice Address - Country:US
Practice Address - Phone:406-293-8711
Practice Address - Fax:406-293-8735
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT34352363A00000X
AK363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant