Provider Demographics
NPI:1629638176
Name:BAUTISTA, ZACHARY ALEXANDER (PA-C)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:ALEXANDER
Last Name:BAUTISTA
Suffix:
Gender:M
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 1:1600 SW ARCHER RD BOX 100186
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0001
Mailing Address - Country:US
Mailing Address - Phone:352-265-5911
Mailing Address - Fax:352-265-5606
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-6954
Practice Address - Country:US
Practice Address - Phone:352-265-5911
Practice Address - Fax:352-265-5606
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112449363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104515500Medicaid