Healthcare Provider Details

I. General information

NPI: 1558979245
Provider Name (Legal Business Name): TYLER VAN BASTIAN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2020
Last Update Date: 07/19/2020
Certification Date: 07/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 LOUISIANA BLVD NE STE 410
ALBUQUERQUE NM
87110-5412
US

IV. Provider business mailing address

5120 ALBERTA AVE NE
RIO RANCHO NM
87144-6482
US

V. Phone/Fax

Practice location:
  • Phone: 505-724-4300
  • Fax:
Mailing address:
  • Phone: 505-615-6368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT5730
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: