Provider Demographics
NPI:1699802926
Name:AL-ADHAM, BASEL (PA-C)
Entity type:Individual
Prefix:MR
First Name:BASEL
Middle Name:
Last Name:AL-ADHAM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3090 VIALE MARCO POLO
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4131
Mailing Address - Country:US
Mailing Address - Phone:702-614-6550
Mailing Address - Fax:702-614-6562
Practice Address - Street 1:3006 S MARYLAND PKWY
Practice Address - Street 2:SUITE 690
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2218
Practice Address - Country:US
Practice Address - Phone:702-732-1290
Practice Address - Fax:702-732-1385
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2020-0008363A00000X
NV421363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVVWCLCQOtherMEDICARE GROUP
NV2402308Medicaid
NVPA421Medicare PIN
NV2402308Medicaid