1437506581 NPI number — MRS. MARY STEPHANIE GANGCUANGCO BAUTISTA FNP

Table of content: (NPI 1568889475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437506581 NPI number — MRS. MARY STEPHANIE GANGCUANGCO BAUTISTA FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAUTISTA
Provider First Name:
MARY STEPHANIE
Provider Middle Name:
GANGCUANGCO
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437506581
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3853 W STETSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HEMET
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92545-9674
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-929-6900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28062 BAXTER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MURRIETA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92563-1401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-534-6114
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  676857 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 95005578 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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