Provider Demographics
NPI:1730530049
Name:BASTATAS, TONI JEN
Entity type:Individual
Prefix:
First Name:TONI JEN
Middle Name:
Last Name:BASTATAS
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 1:44-720 PUAMOHALA ST
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-2449
Mailing Address - Country:US
Mailing Address - Phone:808-349-6836
Mailing Address - Fax:
Practice Address - Street 1:44-720 PUAMOHALA ST
Practice Address - Street 2:
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744-2449
Practice Address - Country:US
Practice Address - Phone:808-349-6836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIHI101017448376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide