Provider Demographics
NPI:1568657641
Name:BAST, DIANA (PA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:BAST
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 1:1534 PARK AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:QUAKERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18951-1084
Mailing Address - Country:US
Mailing Address - Phone:267-424-8850
Mailing Address - Fax:215-538-7907
Practice Address - Street 1:1534 PARK AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:QUAKERTOWN
Practice Address - State:PA
Practice Address - Zip Code:18951-1084
Practice Address - Country:US
Practice Address - Phone:267-424-8850
Practice Address - Fax:215-538-7907
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00181700363AS0400X
PAMA057632363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ140042NMSOtherMEDICARE PTAN