Provider Demographics
NPI:1376801373
Name:NATIVIDAD, SHAY BAUTISTA (RPT)
Entity Type:Individual
Prefix:
First Name:SHAY
Middle Name:BAUTISTA
Last Name:NATIVIDAD
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 HILBORN AVE
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-4224
Mailing Address - Country:US
Mailing Address - Phone:417-437-4379
Mailing Address - Fax:
Practice Address - Street 1:1205 HILBORN AVE
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-4224
Practice Address - Country:US
Practice Address - Phone:417-437-4379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-26
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23785225100000X
PA018544225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist