Provider Demographics
NPI:1598856536
Name:BASTIBLE, KIMBERLY A (MS, RPA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:BASTIBLE
Suffix:
Gender:F
Credentials:MS, RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 HARMONY RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2316
Mailing Address - Country:US
Mailing Address - Phone:631-813-9199
Mailing Address - Fax:
Practice Address - Street 1:18 HARMONY RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2316
Practice Address - Country:US
Practice Address - Phone:631-813-9199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004911363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant