Provider Demographics
NPI:1619552163
Name:BASTEDO, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:BASTEDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 COLUMBUS BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-1976
Mailing Address - Country:US
Mailing Address - Phone:860-837-5560
Mailing Address - Fax:860-837-6387
Practice Address - Street 1:282 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3322
Practice Address - Country:US
Practice Address - Phone:860-837-5506
Practice Address - Fax:860-837-5540
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9357363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics