MEDICARE: SVETLANA BASS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	2108	WI
2	363AM0700X	Medical Physician Assistant	2108	WI

General Provider Information

NPI Number	:	1568584795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SVETLANA BASS PA

Provider Business Mailing Address
First Line	:	9200 W WISCONSIN AVE
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-3522
Country	:	US
Telephone Number	:	414-805-4601
Fax Number	:	414-805-4606

Provider Business Practice Location Address
First Line	:	9200 W WISCONSIN AVE
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-3522
Country	:	US
Telephone Number	:	414-805-4601
Fax Number	:	414-805-4606

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	08/30/2007

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Directions to “ SVETLANA BASS PA” Practice Location

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