Provider Demographics
NPI:1225585649
Name:BASTIAN, BROOKE L (PA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:L
Last Name:BASTIAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1663 W COMMERCE AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-4008
Mailing Address - Country:US
Mailing Address - Phone:602-502-1068
Mailing Address - Fax:
Practice Address - Street 1:8415 N PIMA RD STE 280
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4488
Practice Address - Country:US
Practice Address - Phone:480-245-4425
Practice Address - Fax:480-245-4426
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6536363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ275506Medicaid