Provider Demographics
NPI:1659832673
Name:BASTIAN, MEGHAN MARIE
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:MARIE
Last Name:BASTIAN
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 1:2487 W WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:LUPTON
Mailing Address - State:MI
Mailing Address - Zip Code:48635-9529
Mailing Address - Country:US
Mailing Address - Phone:989-387-1522
Mailing Address - Fax:
Practice Address - Street 1:2487 W WABASH AVE
Practice Address - Street 2:
Practice Address - City:LUPTON
Practice Address - State:MI
Practice Address - Zip Code:48635-9529
Practice Address - Country:US
Practice Address - Phone:989-387-1522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-31
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5601009467363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program