MEDICARE: TARA M. BAUTISTA CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	COA.17460-NP	OH

General Provider Information

NPI Number	:	1205219375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA M. BAUTISTA CNP

Provider Business Mailing Address
First Line	:	5400 FRANTZ RD STE 250
Second Line	:
City	:	DUBLIN
State	:	OH
Zip	:	43016-6102
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5555 CLEVELAND AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43231-4048
Country	:	US
Telephone Number	:	614-788-5280
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2015
Last Update Date	:	03/22/2018

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