Provider Demographics
NPI:1790242139
Name:BAUMAN, AMY SUZANNE (PTA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:SUZANNE
Last Name:BAUMAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9897 ESPADA CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-3532
Mailing Address - Country:US
Mailing Address - Phone:314-518-4349
Mailing Address - Fax:
Practice Address - Street 1:929 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215-2296
Practice Address - Country:US
Practice Address - Phone:661-558-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3880225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant