Provider Demographics
NPI:1609831114
Name:BASSILIOS, MIRANDA NABIL (PA C)
Entity Type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:NABIL
Last Name:BASSILIOS
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:365 HAWTHORNE AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3107
Mailing Address - Country:US
Mailing Address - Phone:510-893-1700
Mailing Address - Fax:510-893-0110
Practice Address - Street 1:365 HAWTHORNE AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3107
Practice Address - Country:US
Practice Address - Phone:510-893-1700
Practice Address - Fax:510-893-0110
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA15948363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant