Provider Demographics
NPI:1104811504
Name:BASTA, JEAN DENISE (MD)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:DENISE
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 1:2301 HOUSE AVE
Mailing Address - Street 2:SUITE 505
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3179
Mailing Address - Country:US
Mailing Address - Phone:307-632-9261
Mailing Address - Fax:307-634-9170
Practice Address - Street 1:2301 HOUSE AVE
Practice Address - Street 2:SUITE 505
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3179
Practice Address - Country:US
Practice Address - Phone:307-632-9261
Practice Address - Fax:307-634-9170
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6885A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118705800Medicaid
P00061023OtherRAILROAD MEDICARE
WY82001A004OtherTRICARE
0726680001OtherDMERC
WY312232OtherBLUE CROSS BLUE SHIELD
WY118705800Medicaid
P00061023OtherRAILROAD MEDICARE