1710621842 NPI number — MRS. PAYTON MARIE HOLDEN BISTA OD

Table of content: MRS. PAYTON MARIE HOLDEN BISTA OD (NPI 1710621842)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710621842 NPI number — MRS. PAYTON MARIE HOLDEN BISTA OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLDEN BISTA
Provider First Name:
PAYTON
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOLDEN
Provider Other First Name:
PAYTON
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710621842
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3325 ANDERS LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53005-2804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-969-2280
Provider Business Mailing Address Fax Number:
414-453-1330

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7511 HARWOOD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAOWATOSA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53213-2606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-453-1300
Provider Business Practice Location Address Fax Number:
414-453-1330
Provider Enumeration Date:
04/25/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  046011619 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 3869-35 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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