Basic Information
| Provider Information | |||||||||
| NPI: | 1336218734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAUTISTA | ||||||||
| FirstName: | JEFFERSON | ||||||||
| MiddleName: | AQUINO | ||||||||
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| Credential: | NP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15090 | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928035090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145772121 | ||||||||
| FaxNumber: | 7145772125 | ||||||||
| Practice Location | |||||||||
| Address1: | 1211 W LA PALMA AVE STE 404 | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928012806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147728282 | ||||||||
| FaxNumber: | 7147726493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 12/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 16338 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 486995 | 01 | CA | RN | OTHER |