Provider Demographics
NPI:1104328095
Name:BASHA, ENAS (NP)
Entity type:Individual
Prefix:MRS
First Name:ENAS
Middle Name:
Last Name:BASHA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1371 SONOMA DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-7833
Mailing Address - Country:US
Mailing Address - Phone:404-252-0256
Mailing Address - Fax:
Practice Address - Street 1:1412 MILSTEAD AVE NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3877
Practice Address - Country:US
Practice Address - Phone:404-605-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA217282363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care