Provider Demographics
NPI:1235829201
Name:BASS, MICHAEL JANSON (PMHNP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JANSON
Last Name:BASS
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42201 N 41ST DR STE 160
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-3803
Mailing Address - Country:US
Mailing Address - Phone:623-206-1190
Mailing Address - Fax:
Practice Address - Street 1:42201 N 41ST DR STE 160
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-3803
Practice Address - Country:US
Practice Address - Phone:623-206-1190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-11
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ291618363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health