Provider Demographics
NPI:1871241950
Name:BASS, COURTNEY LASUMNER (NP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LASUMNER
Last Name:BASS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 W ROOFTOP DR
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-4805
Mailing Address - Country:US
Mailing Address - Phone:801-683-9523
Mailing Address - Fax:
Practice Address - Street 1:1028 W ROOFTOP DR
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-4805
Practice Address - Country:US
Practice Address - Phone:801-683-9523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-16
Last Update Date:2022-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9321350-3102163W00000X
UT9321350-4408363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse