Provider Demographics
NPI:1912969155
Name:BASHOR, GREGORY (MPT)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:BASHOR
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 W WILLIAMS ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-3955
Mailing Address - Country:US
Mailing Address - Phone:919-249-4040
Mailing Address - Fax:919-249-4043
Practice Address - Street 1:1031 W WILLIAMS ST
Practice Address - Street 2:SUITE 103
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-3955
Practice Address - Country:US
Practice Address - Phone:919-249-4040
Practice Address - Fax:919-249-4043
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305006661225100000X
NC7481225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA650015833OtherRAILROAD MEDICARE
VA8928711Medicaid
8928711OtherAETNA
NC079E3OtherBCBS
NC9251105OtherAETNA
NC079E3OtherBCBS
8928711OtherAETNA
VA650000212Medicare PIN