Provider Demographics
NPI:1215709878
Name:BASDEKIS, GABRIELLA GEORGIA
Entity type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:GEORGIA
Last Name:BASDEKIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5115 OLEANDER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-7018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5115 OLEANDER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-7018
Practice Address - Country:US
Practice Address - Phone:910-362-1011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-26
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-13699363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical