Healthcare Provider Details

I. General information

NPI: 1871241950
Provider Name (Legal Business Name): COURTNEY LASUMNER BASS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2022
Last Update Date: 10/20/2024
Certification Date: 10/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 W ROOFTOP DR
MIDVALE UT
84047-4805
US

IV. Provider business mailing address

1028 W ROOFTOP DR
MIDVALE UT
84047-4805
US

V. Phone/Fax

Practice location:
  • Phone: 801-683-9523
  • Fax:
Mailing address:
  • Phone: 801-683-9523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9321350-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9321350-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: