Provider Demographics
NPI:1992465546
Name:BASTIDAS, RICHARD (PT)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:BASTIDAS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10011 STONELAKE BLVD APT 349
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-6096
Mailing Address - Country:US
Mailing Address - Phone:619-403-0115
Mailing Address - Fax:
Practice Address - Street 1:3110 GUADALUPE ST STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-2858
Practice Address - Country:US
Practice Address - Phone:512-675-1359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1352945225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist