Provider Demographics
NPI:1265599674
Name:BASSITY, BRUCE A (PA)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:BASSITY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 KNIK-GOOSEBAY ROAD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654
Mailing Address - Country:US
Mailing Address - Phone:907-631-7889
Mailing Address - Fax:907-631-7612
Practice Address - Street 1:1001 KNIK-GOOSEBAY ROAD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-631-7889
Practice Address - Fax:907-631-7612
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK779363A00000X
NY008720363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDA0120Medicaid
NYDD2004Medicaid
NYDD2004Medicaid