Provider Demographics
NPI:1124329339
Name:BASHAM, KEITH EMORY (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:EMORY
Last Name:BASHAM
Suffix:
Gender:
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 CENTRO FAMILIAR BLVD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-4592
Mailing Address - Country:US
Mailing Address - Phone:505-873-7400
Mailing Address - Fax:
Practice Address - Street 1:7704 2ND ST NW STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-6755
Practice Address - Country:US
Practice Address - Phone:505-873-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3117363A00000X
NMPA2011-0057363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant