Provider Demographics
NPI:1760194534
Name:BAUTISTA, MELISSA KS (MACOM, LAC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:KS
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MACOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3135 SE 89TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266
Mailing Address - Country:US
Mailing Address - Phone:971-226-3539
Mailing Address - Fax:
Practice Address - Street 1:833 SE MAIN ST STE 323
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3427
Practice Address - Country:US
Practice Address - Phone:503-894-0064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-23
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC208634171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist