Provider Demographics
NPI:1356754410
Name:BAUTISTA, JUAN CRISTOBAL
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CRISTOBAL
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 1:1817 N ROAD 32
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-3847
Mailing Address - Country:US
Mailing Address - Phone:509-851-5354
Mailing Address - Fax:
Practice Address - Street 1:1817 N ROAD 32
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-3847
Practice Address - Country:US
Practice Address - Phone:509-851-5354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1070942225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist