Provider Demographics
NPI:1144561028
Name:BAUTISTA, RICHARD FRANKLIN (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:FRANKLIN
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3390 HARDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SARALAND
Mailing Address - State:AL
Mailing Address - Zip Code:36571-4401
Mailing Address - Country:US
Mailing Address - Phone:619-733-2524
Mailing Address - Fax:
Practice Address - Street 1:3390 HARDWOOD DR
Practice Address - Street 2:
Practice Address - City:SARALAND
Practice Address - State:AL
Practice Address - Zip Code:36571-4401
Practice Address - Country:US
Practice Address - Phone:619-733-2524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-02
Last Update Date:2013-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.884363A00000X
FLPA 9107034363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant