Provider Demographics
NPI:1194230417
Name:BASTIAN, MADELLA NONE
Entity Type:Individual
Prefix:
First Name:MADELLA
Middle Name:NONE
Last Name:BASTIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 SW 2ND CT APT 2
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-1891
Mailing Address - Country:US
Mailing Address - Phone:305-525-2147
Mailing Address - Fax:
Practice Address - Street 1:3800 SW 2ND CT APT 2
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1891
Practice Address - Country:US
Practice Address - Phone:305-525-2147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other