Provider Demographics
NPI:1922298934
Name:BASS, MERCEDES C
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:C
Last Name:BASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12027 194TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-3713
Mailing Address - Country:US
Mailing Address - Phone:347-323-9440
Mailing Address - Fax:
Practice Address - Street 1:12027 194TH ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-3713
Practice Address - Country:US
Practice Address - Phone:347-323-9440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY541914163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02531193Medicaid