Healthcare Provider Details

I. General information

NPI: 1013286152
Provider Name (Legal Business Name): LESLIE T. BASTIAN AT,C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

366 E 1100 S
MAPLETON UT
84664-5012
US

IV. Provider business mailing address

366 E 1100 S
MAPLETON UT
84664-5012
US

V. Phone/Fax

Practice location:
  • Phone: 801-491-2199
  • Fax:
Mailing address:
  • Phone: 801-491-2199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateUT

VII. Legacy identifiers

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

# 1
Identifier22
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerPROVIDER CODE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: