Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | E-10368 | AR |
NPI | 1043573355 |
---|---|
Provider Name | Dr. Kyle B Basham |
First Address | Fort Smith, AR 72903-3222 |
Second Address | Knoxville, TN 37920-1511 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2012 |
Last Update Date | 27/03/2018 |