Provider Demographics
NPI:1982622064
Name:BASS, LANESSA D (MD)
Entity type:Individual
Prefix:DR
First Name:LANESSA
Middle Name:D
Last Name:BASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 S BECKHAM AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1908
Mailing Address - Country:US
Mailing Address - Phone:903-590-5612
Mailing Address - Fax:
Practice Address - Street 1:1000 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1908
Practice Address - Country:US
Practice Address - Phone:903-590-5612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4425208000000X
TXM3466208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP00402634OtherRAILROAD MEDICARE
AR158326001Medicaid
AR158326001Medicaid
I33429Medicare UPIN