Provider Demographics
NPI:1114440179
Name:BASS, KEITH SAMUEL (NP-C)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:SAMUEL
Last Name:BASS
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 LYNWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-3265
Mailing Address - Country:US
Mailing Address - Phone:217-898-3462
Mailing Address - Fax:
Practice Address - Street 1:513 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-1668
Practice Address - Country:US
Practice Address - Phone:618-833-4471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015848363LF0000X
IL277002840363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily