Provider Demographics
NPI:1083706873
Name:BAST, CYNTHIA J (PAC)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:J
Last Name:BAST
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 STAGELINE RD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016
Mailing Address - Country:US
Mailing Address - Phone:715-531-6800
Mailing Address - Fax:715-531-6801
Practice Address - Street 1:2310 CRESTVIEW DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016
Practice Address - Country:US
Practice Address - Phone:715-531-6802
Practice Address - Fax:715-531-6803
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9534363A00000X
WI122023363A00000X
WI1220363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP08807Medicare UPIN
P08807Medicare UPIN