Provider Demographics
NPI:1275654287
Name:BAUTISTA, VERNICE ANN R (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:VERNICE ANN
Middle Name:R
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 SAN JUAN AVE
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-3323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2201 SAN JUAN AVE
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-3323
Practice Address - Country:US
Practice Address - Phone:719-384-8181
Practice Address - Fax:719-384-4872
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1565363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant