Provider Demographics
NPI:1912216144
Name:BAUTISTA, HANNIBAL
Entity Type:Individual
Prefix:MR
First Name:HANNIBAL
Middle Name:
Last Name: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 1:1402 LOWES FARM PKWY
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-8614
Mailing Address - Country:US
Mailing Address - Phone:617-817-3017
Mailing Address - Fax:
Practice Address - Street 1:1402 LOWES FARM PKWY
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-8614
Practice Address - Country:US
Practice Address - Phone:617-817-3017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18884225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS39033501OtherDRIVER'S LICENSE