Provider Demographics
NPI:1124110093
Name:BASS-FINCK, SUSAN KAY (PA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAY
Last Name:BASS-FINCK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6547
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-6547
Mailing Address - Country:US
Mailing Address - Phone:903-593-6500
Mailing Address - Fax:903-531-9535
Practice Address - Street 1:1814 ROSELAND BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-4234
Practice Address - Country:US
Practice Address - Phone:903-593-6500
Practice Address - Fax:903-531-9535
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00338363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J3472Medicare PIN