Provider Demographics
NPI:1972856961
Name:BASSEY, SHIRLEY EPHRAIM (PA)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:EPHRAIM
Last Name:BASSEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2187 CHEROKEE VALLEY CIR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-5365
Mailing Address - Country:US
Mailing Address - Phone:404-285-4380
Mailing Address - Fax:
Practice Address - Street 1:55 WHITCHER STREET
Practice Address - Street 2:SUITE 160
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-422-1372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6593363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant