Basic Information
| Provider Information | |||||||||
| NPI: | 1679058986 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASS | ||||||||
| FirstName: | CAMERON | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639008 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7720 US HIGHWAY 98 W STE 240 | ||||||||
| Address2: | |||||||||
| City: | MIRAMAR BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325507232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505025989 | ||||||||
| FaxNumber: | 8502666301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2018 | ||||||||
| LastUpdateDate: | 02/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9112157 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.