Provider Demographics
NPI:1891188702
Name:BASHAM, TIFFANY S
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:S
Last Name:BASHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 GREENFIELD AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-3500
Mailing Address - Country:US
Mailing Address - Phone:559-584-5770
Mailing Address - Fax:888-774-0477
Practice Address - Street 1:200 BRULE STREET
Practice Address - Street 2:
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121
Practice Address - Country:US
Practice Address - Phone:502-626-9681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-17
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011255363LF0000X
TNAPN0000019657363LF0000X
CA95015563363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily