Provider Demographics
NPI:1043967565
Name:BASS, BAILEY
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:
Last Name:BASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 PRINCE ST STE 43
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-3600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2302 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-6297
Practice Address - Country:US
Practice Address - Phone:501-329-3831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-04
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR101732163WC0200X
390200000X
AR220430367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program