Provider Demographics
NPI:1073059374
Name:BAUTISTA, EMMARUTH (PT)
Entity Type:Individual
Prefix:
First Name:EMMARUTH
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 NEVADA AVE APT 110
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1414
Mailing Address - Country:US
Mailing Address - Phone:954-551-0452
Mailing Address - Fax:
Practice Address - Street 1:2330 NEVADA AVE APT 110
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1414
Practice Address - Country:US
Practice Address - Phone:954-551-0452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4649225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist