Healthcare Provider Details

I. General information

NPI: 1285024083
Provider Name (Legal Business Name): ERICKSON CRUZ BAUTISTA D.N.P
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2015
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6926 BROCKTON AVE STE 8
RIVERSIDE CA
92506-3804
US

IV. Provider business mailing address

18411 CRENSHAW BLVD STE 110
TORRANCE CA
90504-5078
US

V. Phone/Fax

Practice location:
  • Phone: 877-414-7739
  • Fax:
Mailing address:
  • Phone: 310-817-5665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95002040
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number822775
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95002040
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number822775
License Number StateNV
# 5
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number822775
License Number StateNV
# 6
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number95002040
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number715867
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: