Provider Demographics
NPI:1679237879
Name:BASCOM, DWIGHT WILLIAM
Entity Type:Individual
Prefix:MR
First Name:DWIGHT
Middle Name:WILLIAM
Last Name:BASCOM
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 1:8602 EXODUS LN
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93312-6181
Mailing Address - Country:US
Mailing Address - Phone:661-706-5497
Mailing Address - Fax:
Practice Address - Street 1:8602 EXODUS LN
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93312-6181
Practice Address - Country:US
Practice Address - Phone:661-706-5497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018888363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner