Provider Demographics
NPI:1881605632
Name:BASS, SUSAN (CNM)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BASS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 E VALLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3048
Mailing Address - Country:US
Mailing Address - Phone:760-739-3144
Mailing Address - Fax:760-739-2926
Practice Address - Street 1:555 E VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3048
Practice Address - Country:US
Practice Address - Phone:760-739-3144
Practice Address - Fax:760-739-2926
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACNMW1333367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife