Provider Demographics
NPI:1720638463
Name:BAUTISTA, IRISH (NP)
Entity Type:Individual
Prefix:
First Name:IRISH
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 TRAVIS ST APT 4048
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77006-3579
Mailing Address - Country:US
Mailing Address - Phone:956-624-5134
Mailing Address - Fax:
Practice Address - Street 1:9721 BROADWAY ST STE 111
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-8170
Practice Address - Country:US
Practice Address - Phone:713-436-3637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-15
Last Update Date:2019-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP140719363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty