Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2100X | Nurse Practitioner - Acute Care | R0032267 | OK |
N | 363LC0200X | Nurse Practitioner - Critical Care Medicine | R0032267 | OK |
NPI | 1336136175 |
---|---|
Provider Name | Mary Bass |
First Address | Tulsa, OK 74136-3347 |
Second Address | Tulsa, OK 74136-1907 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/10/2005 |
Last Update Date | 21/12/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100136240A | (05) | OK |
500018800 | RAILROAD MEDICARE (01) | OK |