Provider Demographics
NPI:1003180423
Name:BAUTISTA, AUDREY ANN (NP)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:ANN
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NW METRO VA CLINIC
Mailing Address - Street 2:1760 GRANDE BLVD
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124
Mailing Address - Country:US
Mailing Address - Phone:505-896-7200
Mailing Address - Fax:505-994-4285
Practice Address - Street 1:NW METRO VA CLINIC
Practice Address - Street 2:1760 GRANDE BLVD
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124
Practice Address - Country:US
Practice Address - Phone:505-896-7200
Practice Address - Fax:505-994-4285
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-01570363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily