Provider Demographics
NPI:1841920220
Name:BASKETT, DIRK KENNETH (PA-C)
Entity type:Individual
Prefix:MR
First Name:DIRK
Middle Name:KENNETH
Last Name:BASKETT
Suffix:
Gender:M
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 1:840 N 4TH E
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-2166
Mailing Address - Country:US
Mailing Address - Phone:208-587-1850
Mailing Address - Fax:
Practice Address - Street 1:840 N 4TH E
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2166
Practice Address - Country:US
Practice Address - Phone:208-587-1850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-2374363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500812528Medicaid