Provider Demographics
NPI:1447849419
Name:BASS, MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BASS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 886
Mailing Address - Street 2:
Mailing Address - City:SUBLIMITY
Mailing Address - State:OR
Mailing Address - Zip Code:97385-0886
Mailing Address - Country:US
Mailing Address - Phone:503-769-2259
Mailing Address - Fax:503-769-8049
Practice Address - Street 1:114 SE CHURCH ST
Practice Address - Street 2:
Practice Address - City:SUBLIMITY
Practice Address - State:OR
Practice Address - Zip Code:97385-9424
Practice Address - Country:US
Practice Address - Phone:503-769-2259
Practice Address - Fax:503-769-8049
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.006828363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH50.006828OtherOHIO MEDICAL BOARD