1922001700 NPI number — STEPHEN D BAST PA-C

Table of content: STEPHEN D BAST PA-C (NPI 1922001700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922001700 NPI number — STEPHEN D BAST PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAST
Provider First Name:
STEPHEN
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922001700
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81008-9000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-553-2208
Provider Business Mailing Address Fax Number:
719-553-2223

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3676 PARKER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81008-2212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-553-2208
Provider Business Practice Location Address Fax Number:
719-553-2223
Provider Enumeration Date:
05/24/2005

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: 363A00000X , with the licence number:  PA.0004346 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 08431701 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".