Provider Demographics
NPI:1932082716
Name:BAUTISTA, ANTHONY (LMT, CPT, CES)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:LMT, CPT, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8631 W ARDENE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-2601
Mailing Address - Country:US
Mailing Address - Phone:208-629-1904
Mailing Address - Fax:
Practice Address - Street 1:8631 W ARDENE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-2601
Practice Address - Country:US
Practice Address - Phone:208-629-1904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-29
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID6971367225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist