Healthcare Provider Details

I. General information

NPI: 1629991104
Provider Name (Legal Business Name): NESTOR BAUTISTA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W 177TH ST APT 53
NEW YORK NY
10033-7119
US

IV. Provider business mailing address

611 W 177TH ST APT 53
NEW YORK NY
10033-7119
US

V. Phone/Fax

Practice location:
  • Phone: 718-913-9811
  • Fax:
Mailing address:
  • Phone: 718-913-9811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number052710
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: