Basic Information
| Provider Information | |||||||||
| NPI: | 1093015885 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASS | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | RUTH | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1202 LOUISIANA AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711013910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182128951 | ||||||||
| FaxNumber: | 3182126752 | ||||||||
| Practice Location | |||||||||
| Address1: | 1811 E BERT KOUNS INDUSTRIAL LOOP STE 400 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182123810 | ||||||||
| FaxNumber: | 3182123815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2010 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA.200391 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2153587 | 05 | LA | MEDICAID |