Provider Demographics
NPI:1093169682
Name:BASTYR, EMILY ROSE (DO)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ROSE
Last Name:BASTYR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:101 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6460
Practice Address - Country:US
Practice Address - Phone:507-385-6500
Practice Address - Fax:507-385-6510
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN62472207Q00000X
MN207Q0000X207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty