Provider Demographics
NPI:1164862058
Name:BASTIAN, ALLISON BROOKE (MD)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:BROOKE
Last Name:BASTIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALLISON
Other - Middle Name:BROOKE
Other - Last Name:OWENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-514-2500
Mailing Address - Fax:208-375-2217
Practice Address - Street 1:777 N RAYMOND ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9251
Practice Address - Country:US
Practice Address - Phone:208-514-2500
Practice Address - Fax:208-375-2217
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMRM-1333207Q00000X
IDM-12732207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1164862058Medicaid
ID20010115Medicare PIN
ID20010113Medicare PIN
ID20010114Medicare PIN
ID20010116Medicare PIN