Provider Demographics
NPI:1063717353
Name:BASER, ELISABETH I (IDC)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:I
Last Name:BASER
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1436 S HWY 116
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-9300
Mailing Address - Country:US
Mailing Address - Phone:858-349-3500
Mailing Address - Fax:
Practice Address - Street 1:PSC 466 BOX 3
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96595-0003
Practice Address - Country:US
Practice Address - Phone:858-349-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman