Basic Information
| Provider Information | |||||||||
| NPI: | 1861565012 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASSHAM | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10827 KANE AVE | ||||||||
| Address2: | |||||||||
| City: | WHITTIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906041825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629443162 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3130 S HARBOR BLVD | ||||||||
| Address2: | 250 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927046824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146198777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 12387 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.