Provider Demographics
NPI:1962453191
Name:BASTIN, CRYSTAL H (MD)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:H
Last Name:BASTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:LEA
Other - Last Name:HEATHERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4605 MACCORKLE AVE SW
Mailing Address - Street 2:THS PHYSICIAN PARTNERS, INC. - ADMIN OFC
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:304-414-4801
Practice Address - Street 1:4820 KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309
Practice Address - Country:US
Practice Address - Phone:304-720-0390
Practice Address - Fax:304-720-0391
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20368207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVB441OtherGROUP MEDICARE
WVB441OtherGROUP MEDICARE
WV4138B441Medicare PIN