Healthcare Provider Details

I. General information

NPI: 1295076081
Provider Name (Legal Business Name): AMBER BAUTISTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2013
Last Update Date: 03/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 S BOULDER AVE
TULSA OK
74119-5234
US

IV. Provider business mailing address

3732 S INDIANAPOLIS AVE 203
TULSA OK
74135-2285
US

V. Phone/Fax

Practice location:
  • Phone: 918-585-1213
  • Fax: 918-743-8845
Mailing address:
  • Phone: 405-565-4496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: