Provider Demographics
NPI:1740799246
Name:BASTIAN, MAYA (CNP)
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:
Last Name:BASTIAN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12220 TRAVOIS RD
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-4241
Mailing Address - Country:US
Mailing Address - Phone:612-799-1793
Mailing Address - Fax:952-942-3803
Practice Address - Street 1:12220 TRAVOIS RD
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55347-4241
Practice Address - Country:US
Practice Address - Phone:952-942-3803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20172669363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics