Provider Demographics
NPI:1942387485
Name:BASS, KENYA DEMETA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KENYA
Middle Name:DEMETA
Last Name:BASS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 SKIBO RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-0261
Mailing Address - Country:US
Mailing Address - Phone:910-864-4357
Mailing Address - Fax:910-221-0099
Practice Address - Street 1:1905 SKIBO RD STE 100
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-0261
Practice Address - Country:US
Practice Address - Phone:910-864-4357
Practice Address - Fax:910-221-0099
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103419363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1942387485Medicaid