Provider Demographics
NPI:1518460435
Name:BAUTISTA GARCIA, JOSE LUIS (NP)
Entity Type:Individual
Prefix:MR
First Name:JOSE LUIS
Middle Name:
Last Name:BAUTISTA GARCIA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12900 PARK PLAZA DR STE 150
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-9329
Mailing Address - Country:US
Mailing Address - Phone:866-646-3553
Mailing Address - Fax:562-622-3058
Practice Address - Street 1:4540 E 7TH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-4327
Practice Address - Country:US
Practice Address - Phone:866-646-3553
Practice Address - Fax:562-622-3058
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-16
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95008698363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty