Provider Demographics
NPI:1699123976
Name:BASIT, WALROSS JIM (CRNA)
Entity type:Individual
Prefix:
First Name:WALROSS
Middle Name:JIM
Last Name:BASIT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4544 BANCROFT AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-4272
Mailing Address - Country:US
Mailing Address - Phone:817-454-3018
Mailing Address - Fax:
Practice Address - Street 1:4544 BANCROFT AVE APT 4
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-4272
Practice Address - Country:US
Practice Address - Phone:817-454-3018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE110041367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered