Provider Demographics
NPI:1841734688
Name:BASHAM, TRACY (FNP)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:
Last Name:BASHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 12TH STREET EXT
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2352
Mailing Address - Country:US
Mailing Address - Phone:304-431-5168
Mailing Address - Fax:
Practice Address - Street 1:401 E VERMILLION ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:WV
Practice Address - Zip Code:24712-8005
Practice Address - Country:US
Practice Address - Phone:304-384-7325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-13
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV49397NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily