Provider Demographics
NPI:1578849758
Name:BASHAM, REBEKAH K (PA-C)
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:K
Last Name:BASHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:REBEKAH
Other - Middle Name:K
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-1510
Mailing Address - Country:US
Mailing Address - Phone:812-450-6815
Mailing Address - Fax:812-450-6822
Practice Address - Street 1:4015 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-8925
Practice Address - Country:US
Practice Address - Phone:812-426-9545
Practice Address - Fax:812-858-4512
Is Sole Proprietor?:No
Enumeration Date:2011-11-01
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001344A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400060067Medicare PIN