MEDICARE: MICHELLE BASTARACHE NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	831764	NV

General Provider Information

NPI Number	:	1053912790
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE BASTARACHE NP

Provider Business Mailing Address
First Line	:	6422 MUSTANG SPRING AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-7200
Country	:	US
Telephone Number	:	702-821-6400
Fax Number	:

Provider Business Practice Location Address
First Line	:	6460 MEDICAL CENTER ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-2406
Country	:	US
Telephone Number	:	702-255-6647
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2020
Last Update Date	:	11/07/2020

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