Provider Demographics
NPI:1376988279
Name:BASS, MAYA ALEXA (MD, MA)
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:ALEXA
Last Name:BASS
Suffix:
Gender:F
Credentials:MD, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 FEDERAL ST
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1539
Mailing Address - Country:US
Mailing Address - Phone:856-583-2400
Mailing Address - Fax:580-596-2805
Practice Address - Street 1:817 FEDERAL ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1539
Practice Address - Country:US
Practice Address - Phone:856-583-2400
Practice Address - Fax:580-596-2805
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-06
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD456215207Q00000X
NJ25MA11105100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1376988279Medicaid