Basic Information
| Provider Information | |||||||||
| NPI: | 1154316081 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAUTISTA | ||||||||
| FirstName: | PRIMO | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 157 | ||||||||
| Address2: | |||||||||
| City: | GRAPEVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 156340157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7245276517 | ||||||||
| FaxNumber: | 7245276519 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | JEANNETTE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 156442505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7245273551 | ||||||||
| FaxNumber: | 7245276519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | MD019326E | PA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 0009369890005 | 05 | PA | MEDICAID | 36621 | 01 | PA | BS | OTHER |