Provider Demographics
NPI:1629963665
Name:AMISTAD, XANDRA MICHELLE BAZAR (BSN, MSN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:XANDRA MICHELLE
Middle Name:BAZAR
Last Name:AMISTAD
Suffix:
Gender:F
Credentials:BSN, MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4712 KENORA DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-1103
Mailing Address - Country:US
Mailing Address - Phone:660-998-4660
Mailing Address - Fax:660-998-4660
Practice Address - Street 1:4712 KENORA DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-1103
Practice Address - Country:US
Practice Address - Phone:660-998-4660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-10
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025020595363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health