Basic Information
| Provider Information | |||||||||
| NPI: | 1124329339 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASHAM | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | EMORY | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1607 VAN CLEAVE RD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871073441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054631730 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 UNIVERSITY OF NEW MEXICO | ||||||||
| Address2: | DEPT. OF EMERGENCY MEDICINE, MSC 6025 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052725062 | ||||||||
| FaxNumber: | 5052726503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2010 | ||||||||
| LastUpdateDate: | 11/20/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3117 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA2011-0057 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.