Provider Demographics
NPI:1407566771
Name:SHRESTHA BASTOLA, SURAJA (DNP)
Entity Type:Individual
Prefix:
First Name:SURAJA
Middle Name:
Last Name:SHRESTHA BASTOLA
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 MORNING VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-5944
Mailing Address - Country:US
Mailing Address - Phone:248-571-2787
Mailing Address - Fax:
Practice Address - Street 1:2845 MORNING VIEW DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-5944
Practice Address - Country:US
Practice Address - Phone:248-571-2787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201907141RN163W00000X
OR10006717363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse