Provider Demographics
NPI:1063815058
Name:BAUTISTA, ERICK
Entity Type:Individual
Prefix:
First Name:ERICK
Middle Name:
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 1:7169 FAIRWEATHER PARK LOOP
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99518-2277
Mailing Address - Country:US
Mailing Address - Phone:251-802-5968
Mailing Address - Fax:
Practice Address - Street 1:7169 FAIRWEATHER PARK LOOP
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99518-2277
Practice Address - Country:US
Practice Address - Phone:251-802-5968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK30814163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse