Provider Demographics
NPI:1457589699
Name:BASTA, AMAYA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:AMAYA
Middle Name:MARIE
Last Name:BASTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 HOMESTEAD DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-3018
Mailing Address - Country:US
Mailing Address - Phone:206-484-0907
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-6241
Practice Address - Country:US
Practice Address - Phone:866-320-4573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1150782085R0202X
IDM132012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology