Provider Demographics
NPI:1871063776
Name:AL-BASHA, AMIRA (PA-C)
Entity type:Individual
Prefix:
First Name:AMIRA
Middle Name:
Last Name:AL-BASHA
Suffix:
Gender:F
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 1:1639 N ALPINE RD STE 380
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1440
Mailing Address - Country:US
Mailing Address - Phone:815-229-9333
Mailing Address - Fax:815-229-7288
Practice Address - Street 1:1639 N ALPINE RD STE 380
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1440
Practice Address - Country:US
Practice Address - Phone:815-229-9333
Practice Address - Fax:815-229-7288
Is Sole Proprietor?:No
Enumeration Date:2018-12-04
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085006967363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program