Provider Demographics
NPI:1568401594
Name:BASTIBLE, BAYLEN CLINT (PA-C)
Entity Type:Individual
Prefix:
First Name:BAYLEN
Middle Name:CLINT
Last Name:BASTIBLE
Suffix:
Gender:M
Credentials:PA-C
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 100189
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76185-0189
Mailing Address - Country:US
Mailing Address - Phone:817-731-0230
Mailing Address - Fax:
Practice Address - Street 1:6551 HARRIS PKWY
Practice Address - Street 2:SUITE 250
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-6103
Practice Address - Country:US
Practice Address - Phone:817-263-6116
Practice Address - Fax:817-263-6117
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04507363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical