Basic Information
| Provider Information | |||||||||
| NPI: | 1639464696 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASTON | ||||||||
| FirstName: | KAITLAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1 FEDERAL ST STE SW200 | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563564924 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3 COOPER PLZ RM 220 | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563422439 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2011 | ||||||||
| LastUpdateDate: | 12/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MA09783500 | NJ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0401X | 25MA09783500 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
No ID Information.