Provider Demographics
NPI:1295076081
Name:BAUTISTA, AMBER
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3732 S INDIANAPOLIS AVE
Mailing Address - Street 2:203
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2285
Mailing Address - Country:US
Mailing Address - Phone:405-565-4496
Mailing Address - Fax:
Practice Address - Street 1:1870 S BOULDER AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74119-5234
Practice Address - Country:US
Practice Address - Phone:918-585-1213
Practice Address - Fax:918-743-8845
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist