Provider Demographics
NPI:1922001700
Name:BAST, STEPHEN D (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:D
Last Name:BAST
Suffix:
Gender:M
Credentials:PA-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 9000
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-9000
Mailing Address - Country:US
Mailing Address - Phone:719-553-2208
Mailing Address - Fax:719-553-2223
Practice Address - Street 1:3676 PARKER BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2212
Practice Address - Country:US
Practice Address - Phone:719-553-2208
Practice Address - Fax:719-553-2223
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004346363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08431701Medicaid
CO08431701Medicaid