Provider Demographics
NPI:1215147046
Name:BASSIS, MARY WILSON (APRN, BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:WILSON
Last Name:BASSIS
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2285 COTTONWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7601
Mailing Address - Country:US
Mailing Address - Phone:801-424-9108
Mailing Address - Fax:
Practice Address - Street 1:2005 E 2700 S STE 180
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-1759
Practice Address - Country:US
Practice Address - Phone:801-746-7190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5207201-8900363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health