Healthcare Provider Details

I. General information

NPI: 1336254705
Provider Name (Legal Business Name): JORGE O BAUTISTA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 CENTRAL AVE
FILLMORE CA
93015-1329
US

IV. Provider business mailing address

427 CENTRAL AVE
FILLMORE CA
93015-1329
US

V. Phone/Fax

Practice location:
  • Phone: 805-524-2559
  • Fax: 805-524-2596
Mailing address:
  • Phone: 805-524-2559
  • Fax: 805-524-2596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA15385
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15385
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: