MEDICARE: DR. ZACHARY N BASTIAN MD

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	208600000X	Surgery Physician	RL10648	ND
2	208600000X	Surgery Physician	12284	ND
3	208600000X	Surgery Physician	MD165259	OR
4	208600000X	Surgery Physician	M-12152	ID

General Provider Information

NPI Number	:	1447412929
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ZACHARY N BASTIAN MD

Provider Business Mailing Address
First Line	:	1024 E LOCUST ST
Second Line	:
City	:	EMMETT
State	:	ID
Zip	:	83617-2776
Country	:	US
Telephone Number	:	208-365-2338
Fax Number	:	208-365-0677

Provider Business Practice Location Address
First Line	:	1024 E LOCUST ST
Second Line	:
City	:	EMMETT
State	:	ID
Zip	:	83617-2776
Country	:	US
Telephone Number	:	208-365-2338
Fax Number	:	208-365-0677

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

Provider Enumeration Date	:	06/26/2008
Last Update Date	:	03/08/2017

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