Provider Demographics
NPI:1922443746
Name:BASTAJIAN, LARA (NP)
Entity Type:Individual
Prefix:MRS
First Name:LARA
Middle Name:
Last Name:BASTAJIAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 ROBINSON DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730-1337
Mailing Address - Country:US
Mailing Address - Phone:617-930-3992
Mailing Address - Fax:
Practice Address - Street 1:344 GREAT RD
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-4004
Practice Address - Country:US
Practice Address - Phone:978-264-9130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-07
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2270224363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily