Healthcare Provider Details

I. General information

NPI: 1801235320
Provider Name (Legal Business Name): JOHN LEE BASS NP, CNS, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 MURRAY AVE TRAUMA & EMERGENCY SURGERY, SVRMC
SAN LUIS OBISPO CA
93405-1806
US

IV. Provider business mailing address

TRAUMA & EMERGENCY SURGERY - 1010 MURRAY AVE. SIERRA VISTA REGIONAL MEDICAL CENTER
SAN LUIS OBIPSO CA
93405
US

V. Phone/Fax

Practice location:
  • Phone: 805-546-7821
  • Fax:
Mailing address:
  • Phone: 805-546-7821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number14574
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code364SE0003X
TaxonomyEmergency Clinical Nurse Specialist
License Number2723
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: