Provider Demographics
NPI:1366200693
Name:BASULTO, TATYANA (PA-C)
Entity type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:BASULTO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N RAMPART ST TRLR 139
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-1819
Mailing Address - Country:US
Mailing Address - Phone:714-675-1793
Mailing Address - Fax:
Practice Address - Street 1:325 E 7TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90014-2209
Practice Address - Country:US
Practice Address - Phone:213-893-1960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA64098363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant