MEDICARE: BAYLEN CLINT BASTIBLE PA-C

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	363AM0700X	Medical Physician Assistant	PA04507	TX

General Provider Information

NPI Number	:	1568401594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BAYLEN CLINT BASTIBLE PA-C

Provider Business Mailing Address
First Line	:	PO BOX 100189
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76185-0189
Country	:	US
Telephone Number	:	817-731-0230
Fax Number	:

Provider Business Practice Location Address
First Line	:	6551 HARRIS PKWY
Second Line	:	SUITE 250
City	:	FORT WORTH
State	:	TX
Zip	:	76132-6103
Country	:	US
Telephone Number	:	817-263-6116
Fax Number	:	817-263-6117

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

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	05/07/2019

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Directions to “ BAYLEN CLINT BASTIBLE PA-C” Practice Location

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