MEDICARE: MARY WILSON BASSIS APRN, BC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	5207201-8900	UT

General Provider Information

NPI Number	:	1215147046
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY WILSON BASSIS APRN, BC

Provider Business Mailing Address
First Line	:	2285 COTTONWOOD CIR
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84117-7601
Country	:	US
Telephone Number	:	801-424-9108
Fax Number	:

Provider Business Practice Location Address
First Line	:	2005 E 2700 S STE 180
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1759
Country	:	US
Telephone Number	:	801-746-7190
Fax Number	:

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

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	07/12/2007

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