Provider Demographics
NPI:1235829201
Name:BASS, MICHAEL JANSON (PMHNP)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JANSON
Last Name:BASS
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 N CENTRAL AVE STE 1050
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1217
Mailing Address - Country:US
Mailing Address - Phone:602-376-3353
Mailing Address - Fax:
Practice Address - Street 1:1840 N 95TH AVE STE 132
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-4445
Practice Address - Country:US
Practice Address - Phone:623-932-6950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-11
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN181884163WP0808X
AZ291618363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health