Basic Information
| Provider Information | |||||||||
| NPI: | 1588647002 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASSHAM | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2488 E 81ST ST STE 290 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741374265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184942665 | ||||||||
| FaxNumber: | 9189273193 | ||||||||
| Practice Location | |||||||||
| Address1: | 2488 E 81ST ST STE 290 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741374265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184942665 | ||||||||
| FaxNumber: | 9189273201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 05/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 1371 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 1371 | OK | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100180730A | 05 | OK | MEDICAID |