Provider Demographics
NPI:1649256587
Name:BAST, RICHIE PATTERSON (MD)
Entity type:Individual
Prefix:DR
First Name:RICHIE
Middle Name:PATTERSON
Last Name:BAST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RICHIE
Other - Middle Name:P
Other - Last Name:BAST MD INCORPORATED
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2910
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:AZ
Mailing Address - Zip Code:85936-2910
Mailing Address - Country:US
Mailing Address - Phone:928-337-4802
Mailing Address - Fax:928-337-3638
Practice Address - Street 1:110 E. 1ST SOUTH STREET
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:AZ
Practice Address - Zip Code:85936-2910
Practice Address - Country:US
Practice Address - Phone:928-337-4802
Practice Address - Fax:928-337-3638
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14854207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ238338Medicaid
AZ238338Medicaid
AZZ101774Medicare ID - Type Unspecified