Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VX0000X | Obstetrician | 36649 | NC |
NPI | 1144222787 |
---|---|
Provider Name | Mr. Brian Edmond Bass |
First Address | Raleigh, NC 27609-6503 |
Second Address | Raleigh, NC 27609-6503 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2005 |
Last Update Date | 29/06/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8913868 | (05) | NC |
F63220 | (02) |