MEDICARE: SUSAN V. BASTA APRN

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	363L00000X	Nurse Practitioner	212263-4405	UT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	130024988	OTHER	UT	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1952491581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN V. BASTA APRN

Provider Business Mailing Address
First Line	:	PO BOX 413034
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84141-3034
Country	:	US
Telephone Number	:	801-213-3900
Fax Number	:

Provider Business Practice Location Address
First Line	:	546 E CHIPETA WAY STE 220
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1221
Country	:	US
Telephone Number	:	801-581-7172
Fax Number	:

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

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	10/21/2021

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