Basic Information
Provider Information
NPI: 1003001025
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BASS
FirstName: MARIA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 9499 W CHARLESTON
Address2: SUITE 250
City: LAS VEGAS
State: NV
PostalCode: 89117
CountryCode: US
TelephoneNumber: 7029333600
FaxNumber:  
Practice Location
Address1: 9499 W CHARLESTON
Address2: #200 OSSM
City: LAS VEGAS
State: NV
PostalCode: 89117
CountryCode: US
TelephoneNumber: 7029333600
FaxNumber: 7029333601
Other Information
ProviderEnumerationDate: 09/12/2007
LastUpdateDate: 09/12/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363AS0400X  Y Physician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical

No ID Information.


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