Provider Demographics
NPI:1710301684
Name:BASHAM, NICHOLAS (PA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:BASHAM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 N RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-3127
Mailing Address - Country:US
Mailing Address - Phone:931-542-9420
Mailing Address - Fax:931-542-9422
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-412-5122
Practice Address - Fax:270-412-5168
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
TNPA0000002721363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical