Provider Demographics
NPI:1407064405
Name:BASTIDAS, ERIN
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:BASTIDAS
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:PO BOX 13579
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19612-3579
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:146 S READING AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BOYERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19512-1480
Practice Address - Country:US
Practice Address - Phone:610-369-7121
Practice Address - Fax:610-369-0389
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014699207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA193479OtherMEDICARE
PA102476325Medicaid