Provider Demographics
NPI:1710322896
Name:BAST, PATRICIA ROSE (DO)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ROSE
Last Name:BAST
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:ROSE
Other - Last Name:BLEDSOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:780 CANTON RD NE
Mailing Address - Street 2:STE 200
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060
Mailing Address - Country:US
Mailing Address - Phone:770-285-8026
Mailing Address - Fax:
Practice Address - Street 1:780 CANTON RD NE
Practice Address - Street 2:STE 200
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-285-8026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA174N00000X
CA20A14128208000000X
GA82246208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice