Provider Demographics
NPI:1073263992
Name:BASTIAN, INGMAR NIELS (STUDENT)
Entity Type:Individual
Prefix:
First Name:INGMAR
Middle Name:NIELS
Last Name:BASTIAN
Suffix:
Gender:M
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3006 BLUFF ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3422
Mailing Address - Country:US
Mailing Address - Phone:415-272-9528
Mailing Address - Fax:
Practice Address - Street 1:1 BAYLOR PLZ
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3411
Practice Address - Country:US
Practice Address - Phone:832-826-7354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WISTUDENT207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology