Healthcare Provider Details

I. General information

NPI: 1548672454
Provider Name (Legal Business Name): ANDREA BASS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2014
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEPT OF THE ARMY, BG SAMS, USAMEDDAC-JAPAN MCJA-NUR UNIT 45011
APO AP
96338-5011
US

IV. Provider business mailing address

CMR 427 BOX 3927
APO AE
09630-0040
US

V. Phone/Fax

Practice location:
  • Phone: 315-263-8206
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number0001164538
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: