Healthcare Provider Details

I. General information

NPI: 1710521950
Provider Name (Legal Business Name): ALLISON ROSE BASSAM HARB PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2019
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ELLIOT WAY
MANCHESTER NH
03103-3502
US

IV. Provider business mailing address

1 ELLIOT WAY
MANCHESTER NH
03103-3502
US

V. Phone/Fax

Practice location:
  • Phone: 603-663-2710
  • Fax:
Mailing address:
  • Phone: 603-663-2710
  • Fax: 603-663-2273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1998
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1846
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: