Provider Demographics
NPI:1598923476
Name:BASTA, ROBERT D (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:D
Last Name:BASTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:33501 1ST WAY S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6208
Mailing Address - Country:US
Mailing Address - Phone:253-838-2400
Mailing Address - Fax:253-874-1634
Practice Address - Street 1:33501 1ST WAY S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6208
Practice Address - Country:US
Practice Address - Phone:253-838-2400
Practice Address - Fax:253-874-1634
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-28
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00031776207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD00031776OtherLICENSE NUMBER
WA0285088OtherLABOR AND INDUSTRY
WAMD00031776OtherLICENSE NUMBER