Provider Demographics
NPI:1699143792
Name:BASTIAN, MECHELLE
Entity type:Individual
Prefix:
First Name:MECHELLE
Middle Name:
Last Name:BASTIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E SONTERRA BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4299
Mailing Address - Country:US
Mailing Address - Phone:210-496-7999
Mailing Address - Fax:
Practice Address - Street 1:700 E SONTERRA BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4299
Practice Address - Country:US
Practice Address - Phone:210-496-7999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-04
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128505363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily