Provider Demographics
NPI:1972026169
Name:BASSO, LIA RUTH (PA-C)
Entity Type:Individual
Prefix:
First Name:LIA
Middle Name:RUTH
Last Name:BASSO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE KATRINE
Mailing Address - State:NY
Mailing Address - Zip Code:12449-5342
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 GRANT AVE
Practice Address - Street 2:
Practice Address - City:LAKE KATRINE
Practice Address - State:NY
Practice Address - Zip Code:12449-5342
Practice Address - Country:US
Practice Address - Phone:845-339-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-20
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020881-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant