Provider Demographics
NPI:1407195613
Name:BAUTISTA, BRYAN B (DPT)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:B
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 HAMPTON HILLS DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-3868
Mailing Address - Country:US
Mailing Address - Phone:352-650-9356
Mailing Address - Fax:
Practice Address - Street 1:3705 HAMPTON HILLS DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810-3868
Practice Address - Country:US
Practice Address - Phone:352-650-9356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 23113225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist