Basic Information
| Provider Information | |||||||||
| NPI: | 1962589077 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASTIAN | ||||||||
| FirstName: | GAIL | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | PHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 157 ANYA RD | ||||||||
| Address2: | |||||||||
| City: | CORRALES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870488582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052651711 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 454 SAINT MICHAELS DR | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053035000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 11/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | RP00006061 | NM | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.