Provider Demographics
NPI:1043056443
Name:BASS, LADONNA M
Entity type:Individual
Prefix:
First Name:LADONNA
Middle Name:M
Last Name:BASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 RANDOLPH CT
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-7929
Mailing Address - Country:US
Mailing Address - Phone:229-220-0238
Mailing Address - Fax:
Practice Address - Street 1:920 S WEST ST
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-4581
Practice Address - Country:US
Practice Address - Phone:229-246-8850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-04
Last Update Date:2024-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN297220207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine