Provider Demographics
NPI:1265403851
Name:BASILICATO, SUSAN (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BASILICATO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 BEALL LN
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-1573
Mailing Address - Country:US
Mailing Address - Phone:541-664-5151
Mailing Address - Fax:
Practice Address - Street 1:1200 MIRA MAR AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8546
Practice Address - Country:US
Practice Address - Phone:541-664-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR07804146RN163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR114953Medicare PIN