Healthcare Provider Details

I. General information

NPI: 1497307664
Provider Name (Legal Business Name): BRYCE BASS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2019
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 DALLAS STREET
FORT SMITH AR
72903-5690
US

IV. Provider business mailing address

7900 DALLAS STREET
FORT SMITH AR
72903-5690
US

V. Phone/Fax

Practice location:
  • Phone: 479-242-6647
  • Fax: 479-250-0505
Mailing address:
  • Phone: 479-242-6647
  • Fax: 479-250-0505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA854
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: