Healthcare Provider Details

I. General information

NPI: 1396351805
Provider Name (Legal Business Name): MARY ELIZABETH BASTIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2020
Last Update Date: 09/20/2020
Certification Date: 09/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 S MILL AVE
TEMPE AZ
85281-6600
US

IV. Provider business mailing address

4950 E VAN BUREN ST APT 372
PHOENIX AZ
85008-7054
US

V. Phone/Fax

Practice location:
  • Phone: 480-967-1661
  • Fax:
Mailing address:
  • Phone: 585-743-0508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: