Provider Demographics
NPI:1104557040
Name:BAUTISTA, ANTHONY OSCAR
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:OSCAR
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7855 CAMERON WAY
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509-0152
Mailing Address - Country:US
Mailing Address - Phone:323-217-4348
Mailing Address - Fax:
Practice Address - Street 1:3576 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3943
Practice Address - Country:US
Practice Address - Phone:559-644-7742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker