Healthcare Provider Details

I. General information

NPI: 1760207849
Provider Name (Legal Business Name): MARLON BAUTISTA RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2024
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 MIRANDA AVE
PALO ALTO CA
94304-1207
US

IV. Provider business mailing address

5287 CARLINO CT
ANTIOCH CA
94531-5019
US

V. Phone/Fax

Practice location:
  • Phone: 650-493-5000
  • Fax: 650-858-8920
Mailing address:
  • Phone: 510-326-7033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0400X
TaxonomyRehabilitation Registered Nurse
License Number651510
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: