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General NPI Number Information
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NPI Number | 1255875266
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Entity Type | Individual
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Provider Name | MADELINE ANN BASSE P.A.
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Gender | Female
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Dates
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Enumeration Date | 12/09/2016
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Last Update Date | 12/21/2016
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Provider Practice Location Address
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Address Line | 400 W 16TH ST SCEMA
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City | PUEBLO
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State | CO
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Zip | 81003-2745
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Country | US
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Telephone | 719-584-4306
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1881
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City | PUEBLO
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State | CO
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Zip | 81002-1881
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Country | US
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Telephone | 719-584-4306
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA.0004873
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License Number State | CO
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