Provider Demographics
NPI:1588921738
Name:BASHAM, RICHARD D (ARNP)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
Last Name:BASHAM
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 CEDAR RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-8002
Mailing Address - Country:US
Mailing Address - Phone:270-971-1388
Mailing Address - Fax:270-297-7066
Practice Address - Street 1:332 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-1428
Practice Address - Country:US
Practice Address - Phone:270-971-1388
Practice Address - Fax:270-297-7066
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-12
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007397363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12436388OtherCAQH
KY46-2412498OtherEIN