Provider Demographics
NPI:1629724075
Name:SANCHEZ BASTIDAS, JOSE RAMON (NP-C)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:RAMON
Last Name:SANCHEZ BASTIDAS
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 617
Mailing Address - Street 2:
Mailing Address - City:SOMERTON
Mailing Address - State:AZ
Mailing Address - Zip Code:85350-0617
Mailing Address - Country:US
Mailing Address - Phone:928-315-7910
Mailing Address - Fax:928-722-6113
Practice Address - Street 1:1453 N MAIN STREET
Practice Address - Street 2:SUITE 6
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85336
Practice Address - Country:US
Practice Address - Phone:928-459-3508
Practice Address - Fax:928-459-3515
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-24
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ271774363LF0000X
AZRN180685163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ121183Medicaid