Provider Demographics
NPI:1164580999
Name:BASTIAN, NEIL (MS, PT)
Entity Type:Individual
Prefix:MR
First Name:NEIL
Middle Name:
Last Name:BASTIAN
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-2312
Mailing Address - Country:US
Mailing Address - Phone:503-697-0542
Mailing Address - Fax:503-697-4895
Practice Address - Street 1:870 5TH ST
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-2312
Practice Address - Country:US
Practice Address - Phone:503-697-0542
Practice Address - Fax:503-697-4895
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2021225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR115801Medicare UPIN