Provider Demographics
NPI:1043616972
Name:BASTIDAS, CARLOS M (RN-BSN)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:M
Last Name:BASTIDAS
Suffix:
Gender:M
Credentials:RN-BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6360 98TH ST
Mailing Address - Street 2:APARTMENT B-17
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2238
Mailing Address - Country:US
Mailing Address - Phone:917-705-9578
Mailing Address - Fax:
Practice Address - Street 1:6360 98TH ST
Practice Address - Street 2:APARTMENT B-17
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2238
Practice Address - Country:US
Practice Address - Phone:917-705-9578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY561861163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency