Healthcare Provider Details

I. General information

NPI: 1235729278
Provider Name (Legal Business Name): CLAIRE BAUTISTA LAZARO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2021
Last Update Date: 01/23/2021
Certification Date: 01/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3440 MCHENRY AVE STE D6
MODESTO CA
95350-1469
US

IV. Provider business mailing address

2265 MAVERICK CT
MODESTO CA
95355-7991
US

V. Phone/Fax

Practice location:
  • Phone: 209-529-1542
  • Fax:
Mailing address:
  • Phone: 209-818-8394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95013171
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: