Provider Demographics
NPI:1487367652
Name:BASCOM, MARTINA EVONNE
Entity type:Individual
Prefix:MISS
First Name:MARTINA
Middle Name:EVONNE
Last Name:BASCOM
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MARTINA
Other - Middle Name:EVONNE
Other - Last Name:YOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5905 O ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2235
Mailing Address - Country:US
Mailing Address - Phone:402-436-1657
Mailing Address - Fax:
Practice Address - Street 1:700 PENROSE DRIVE
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521
Practice Address - Country:US
Practice Address - Phone:402-436-1222
Practice Address - Fax:402-458-3222
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider