Provider Demographics
NPI:1588661375
Name:BASKA, MARLENE G (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARLENE
Middle Name:G
Last Name:BASKA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 DEMOSS STREET
Mailing Address - Street 2:
Mailing Address - City:LORDSBURG
Mailing Address - State:NM
Mailing Address - Zip Code:88045-2618
Mailing Address - Country:US
Mailing Address - Phone:575-542-8384
Mailing Address - Fax:575-542-8367
Practice Address - Street 1:530 DEMOSS STREET
Practice Address - Street 2:
Practice Address - City:LORDSBURG
Practice Address - State:NM
Practice Address - Zip Code:88045-2618
Practice Address - Country:US
Practice Address - Phone:575-542-8384
Practice Address - Fax:575-542-8367
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM94-PA28363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM91430089Medicaid
S15291Medicare UPIN
S15291Medicare Oscar/Certification
349415905Medicare PIN