Healthcare Provider Details

I. General information

NPI: 1609866045
Provider Name (Legal Business Name): VIRGINIA BASTIAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 S 9TH ST
MILWAUKEE WI
53204-1335
US

IV. Provider business mailing address

4376 S 52ND ST
GREENFIELD WI
53220-3570
US

V. Phone/Fax

Practice location:
  • Phone: 414-643-6441
  • Fax:
Mailing address:
  • Phone: 414-520-5483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number63658-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: