Basic Information
| Provider Information | |||||||||
| NPI: | 1225432917 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASHIR | ||||||||
| FirstName: | MAAMAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2650 | ||||||||
| Address2: | |||||||||
| City: | PINE BLUFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716132650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148056850 | ||||||||
| FaxNumber: | 4148056851 | ||||||||
| Practice Location | |||||||||
| Address1: | 4747 DUSTY LAKE DR. | ||||||||
| Address2: | SUITE G1 | ||||||||
| City: | PINE BLUFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705416015 | ||||||||
| FaxNumber: | 4148056851 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2014 | ||||||||
| LastUpdateDate: | 01/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 68019 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1225432917 | 05 | WI | MEDICAID |