Provider Demographics
NPI:1336707132
Name:MUSA, BASAM
Entity Type:Individual
Prefix:
First Name:BASAM
Middle Name:
Last Name:MUSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3926 HIGHWAY 28 E APT 1501
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-5856
Mailing Address - Country:US
Mailing Address - Phone:318-794-9960
Mailing Address - Fax:318-445-2963
Practice Address - Street 1:3926 HIGHWAY 28 E APT 1501
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-5856
Practice Address - Country:US
Practice Address - Phone:318-794-9960
Practice Address - Fax:318-445-2963
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA660227462Medicaid
LA664802073Medicaid
LA802192167Medicaid
LA84-1906921Medicaid