Provider Demographics
NPI:1578913372
Name:BASTIEN, KILEY ALYSSA (PA-C)
Entity Type:Individual
Prefix:
First Name:KILEY
Middle Name:ALYSSA
Last Name:BASTIEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KILEY
Other - Middle Name:
Other - Last Name:TOBEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:7500 CHALLIS RD
Practice Address - Street 2:FLOOR 2
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-9416
Practice Address - Country:US
Practice Address - Phone:734-936-4054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007777363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical