Provider Demographics
NPI:1598274466
Name:BASTA, AGNIESZKA STANISLAWA (APN)
Entity Type:Individual
Prefix:MRS
First Name:AGNIESZKA
Middle Name:STANISLAWA
Last Name:BASTA
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24522 NORTH KELSEY ROAD
Mailing Address - Street 2:
Mailing Address - City:LAKE BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010
Mailing Address - Country:US
Mailing Address - Phone:847-224-4576
Mailing Address - Fax:
Practice Address - Street 1:1201 EAGLE STREET
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432
Practice Address - Country:US
Practice Address - Phone:815-740-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-23
Last Update Date:2017-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016452363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily