Provider Demographics
NPI:1548672454
Name:BASS, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
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:CMR 427 BOX 3927
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09630-0040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:DEPT OF THE ARMY, BG SAMS, USAMEDDAC-JAPAN
Practice Address - Street 2:MCJA-NUR UNIT 45011
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96338-5011
Practice Address - Country:US
Practice Address - Phone:315-263-8206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001164538261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care