Provider Demographics
NPI:1235710039
Name:LARIOS BAUTISTA, ERICK
Entity Type:Individual
Prefix:
First Name:ERICK
Middle Name:
Last Name:LARIOS 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 1:340 KINGSLAND ST
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-1150
Mailing Address - Country:US
Mailing Address - Phone:973-542-6678
Mailing Address - Fax:
Practice Address - Street 1:340 KINGSLAND ST
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-1150
Practice Address - Country:US
Practice Address - Phone:973-542-6678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program