Basic Information
| Provider Information | |||||||||
| NPI: | 1962039289 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAUTISTA | ||||||||
| FirstName: | TRICIA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 907 17TH STREET | ||||||||
| Address2: | APT A | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904033241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107080921 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1025 N DOUTY ST | ||||||||
| Address2: | |||||||||
| City: | HANFORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932303722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595370224 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2020 | ||||||||
| LastUpdateDate: | 03/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.