Provider Demographics
NPI:1659083590
Name:BASCO, RYAN ANDREW
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:ANDREW
Last Name:BASCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10018 PRINCESS CUT ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-6283
Mailing Address - Country:US
Mailing Address - Phone:310-925-9950
Mailing Address - Fax:
Practice Address - Street 1:10018 PRINCESS CUT ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89183-6283
Practice Address - Country:US
Practice Address - Phone:310-925-9950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-22
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVA-1479225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant