Provider Demographics
NPI:1487682571
Name:BAUTISTA-QUAN, MA. LEAH CYNTHIA (PT)
Entity Type:Individual
Prefix:
First Name:MA. LEAH
Middle Name:CYNTHIA
Last Name:BAUTISTA-QUAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:CYNTHIA
Other - Last Name:BAUTISTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:5702 MONOCACY DR
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18017-8236
Mailing Address - Country:US
Mailing Address - Phone:917-916-9298
Mailing Address - Fax:
Practice Address - Street 1:936 W END AVE
Practice Address - Street 2:APT E3
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-3554
Practice Address - Country:US
Practice Address - Phone:917-916-9298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0-19849-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQM4052OtherBLUECROSS/BLUESHIELD
NYQM4051Medicare PIN