Basic Information
| Provider Information | |||||||||
| NPI: | 1518460435 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAUTISTA GARCIA | ||||||||
| FirstName: | JOSE LUIS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12900 PARK PLAZA DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | CERRITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907039329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666463553 | ||||||||
| FaxNumber: | 5626223058 | ||||||||
| Practice Location | |||||||||
| Address1: | 4540 E 7TH ST | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908044327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666463553 | ||||||||
| FaxNumber: | 5626223058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2018 | ||||||||
| LastUpdateDate: | 10/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP95008698 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.