Provider Demographics
NPI:1164665444
Name:BAUTISTA, ANDRE BARRANDA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:BARRANDA
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1304 FAWCETT AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-1911
Mailing Address - Country:US
Mailing Address - Phone:253-761-4200
Mailing Address - Fax:253-383-3553
Practice Address - Street 1:1304 FAWCETT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1911
Practice Address - Country:US
Practice Address - Phone:253-761-4200
Practice Address - Fax:253-383-3553
Is Sole Proprietor?:No
Enumeration Date:2009-04-15
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD605451392085R0204X, 2085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2044117Medicaid
WAG8941909Medicare PIN
WA2044117Medicaid
WAP01528800Medicare PIN
WAP01528803Medicare PIN
WAG8941913Medicare PIN