Provider Demographics
NPI:1043245467
Name:BASTIAN, BRETT ALLEN (PAC)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:ALLEN
Last Name:BASTIAN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1210 W 18TH ST
Practice Address - Street 2:STE 104
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-4647
Practice Address - Country:US
Practice Address - Phone:605-328-8660
Practice Address - Fax:605-328-8661
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0439363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6821692Medicaid
SDS102972Medicare PIN
SDS102037Medicare PIN
SD6821692Medicaid
S26991Medicare UPIN