Healthcare Provider Details

I. General information

NPI: 1033525282
Provider Name (Legal Business Name): KALLIE M BASHOR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 10/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 OSTRUM ST
FOUNTAIN HILL PA
18015-1013
US

IV. Provider business mailing address

2033 W HIGHLAND ST
ALLENTOWN PA
18104-3741
US

V. Phone/Fax

Practice location:
  • Phone: 908-859-6722
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3351-23
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA057499
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: