Provider Demographics
NPI:1053142463
Name:BAUTISTA, JONATHAN (DPT)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6631 CREEPING THYME ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-4801
Mailing Address - Country:US
Mailing Address - Phone:775-742-7133
Mailing Address - Fax:
Practice Address - Street 1:4000 S EASTERN AVE STE 150
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-0840
Practice Address - Country:US
Practice Address - Phone:725-726-7847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6522225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist