Provider Demographics
NPI:1912487455
Name:BAUTISTA, MARK GERARD D (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK GERARD
Middle Name:D
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:4881 SUGAR MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:WRIGHT PAT
Mailing Address - State:OH
Mailing Address - Zip Code:45433-5529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:104 W D. L. INGRAM AVE.
Practice Address - Street 2:CANNON AFB
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:575-904-3831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS390200000-XOtherSTUDENT