Provider Demographics
NPI:1225258445
Name:BAUTISTA, MARIE ANGELA (MS, PA-C)
Entity Type:Individual
Prefix:MS
First Name:MARIE ANGELA
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:BAUTISTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:MC 8892
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:619-543-7777
Practice Address - Fax:619-543-2652
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18241363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18241Medicare UPIN