Healthcare Provider Details

I. General information

NPI: 1568657641
Provider Name (Legal Business Name): DIANA BAST PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 05/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1534 PARK AVE SUITE 210
QUAKERTOWN PA
18951-1084
US

IV. Provider business mailing address

1534 PARK AVE SUITE 210
QUAKERTOWN PA
18951-1084
US

V. Phone/Fax

Practice location:
  • Phone: 267-424-8850
  • Fax: 215-538-7907
Mailing address:
  • Phone: 267-424-8850
  • Fax: 215-538-7907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00181700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA057632
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier140042NMS
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerMEDICARE PTAN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: