Provider Demographics
NPI:1669868535
Name:BASS, KAYLIN MARIE
Entity type:Individual
Prefix:
First Name:KAYLIN
Middle Name:MARIE
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 1:39450 W 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-3600
Mailing Address - Country:US
Mailing Address - Phone:313-651-1961
Mailing Address - Fax:313-447-1102
Practice Address - Street 1:39450 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-3600
Practice Address - Country:US
Practice Address - Phone:313-651-1961
Practice Address - Fax:313-447-1102
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-08
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008032363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty