Provider Demographics
NPI:1053010553
Name:BASTIDAS, BETZALEE (CPT)
Entity type:Individual
Prefix:
First Name:BETZALEE
Middle Name:
Last Name:BASTIDAS
Suffix:
Gender:F
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 FOSTERTOWN RD APT 1
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-8883
Mailing Address - Country:US
Mailing Address - Phone:845-391-4275
Mailing Address - Fax:
Practice Address - Street 1:521 FOSTERTOWN RD APT 1
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-8883
Practice Address - Country:US
Practice Address - Phone:845-391-4275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374700000XNursing Service Related ProvidersTechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY92-2523654Medicaid