Basic Information
| Provider Information | |||||||||
| NPI: | 1356819239 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAUTISTA | ||||||||
| FirstName: | ALEJANDRO | ||||||||
| MiddleName: | ANDRES | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1450 CHAPEL ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065114405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037893000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1450 CHAPEL ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065114405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037893000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2018 | ||||||||
| LastUpdateDate: | 04/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 11/16/2018 | ||||||||
| NPIReactivationDate: | 11/28/2018 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0200X | 134050 | CT | N | Nursing Service Providers | Registered Nurse | Critical Care Medicine | 367500000X | 7987 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.