Provider Demographics
NPI:1285898999
Name:BASULTO, RACHEL S (PA-C)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:S
Last Name:BASULTO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:
Other - Last Name:SOARES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10470 OLD PLACERVILLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-972-5547
Mailing Address - Fax:
Practice Address - Street 1:7420 GREENHAVEN DR STE 130
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95831-5164
Practice Address - Country:US
Practice Address - Phone:916-399-6015
Practice Address - Fax:916-394-3344
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19805363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant