Provider Demographics
NPI:1811419369
Name:DE OLIVEIRA BAUTISTA, PABLO
Entity Type:Individual
Prefix:
First Name:PABLO
Middle Name:
Last Name:DE OLIVEIRA BAUTISTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 E FIRELIGHT WAY
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-4944
Mailing Address - Country:US
Mailing Address - Phone:954-397-6406
Mailing Address - Fax:
Practice Address - Street 1:10894 S RIVER FRONT PKWY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5609
Practice Address - Country:US
Practice Address - Phone:801-302-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-15
Last Update Date:2017-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program