=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790242139
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY SUZANNE BAUMAN PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2019
-----------------------------------------------------
Last Update Date | 02/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 929 JEFFERSON ST
-----------------------------------------------------
City | DELANO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93215-2296
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-558-1100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9897 ESPADA CREEK RD
-----------------------------------------------------
City | MORENO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92557-3532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-518-4349
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 3880
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------