Provider Demographics
NPI:1255676672
Name:BAUTISTA, PHILLIP (PTA)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 239
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-0239
Mailing Address - Country:US
Mailing Address - Phone:845-615-1585
Mailing Address - Fax:
Practice Address - Street 1:30 HATFIELD LN
Practice Address - Street 2:SUITE 203
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-6766
Practice Address - Country:US
Practice Address - Phone:845-615-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008174225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant