Provider Demographics
NPI:1811631435
Name:BASHAM, ROSS
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:BASHAM
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 1:126 TRAILS END CT
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-9071
Mailing Address - Country:US
Mailing Address - Phone:270-791-4819
Mailing Address - Fax:
Practice Address - Street 1:126 TRAILS END CT
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-9071
Practice Address - Country:US
Practice Address - Phone:270-791-4819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1011322706Medicaid