Provider Demographics
NPI:1073242137
Name:BASTIN, GRAYSON (DO)
Entity Type:Individual
Prefix:
First Name:GRAYSON
Middle Name:
Last Name:BASTIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 COLLINS RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-8394
Mailing Address - Country:US
Mailing Address - Phone:517-975-6000
Mailing Address - Fax:
Practice Address - Street 1:2900 COLLINS RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-8394
Practice Address - Country:US
Practice Address - Phone:517-975-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151015495390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program