Provider Demographics
NPI:1174744395
Name:BAUTISTA, ELLEN PRISCILLA SAQUETON (MD)
Entity type:Individual
Prefix:
First Name:ELLEN PRISCILLA
Middle Name:SAQUETON
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:1003 PROVIDENCE DR
Practice Address - Street 2:SUITE 210
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-7521
Practice Address - Country:US
Practice Address - Phone:503-537-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125052040390200000X
ORMD126320207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500614683Medicaid
ORP01034673OtherRR MEDICARE
OR500614683Medicaid