Provider Demographics
NPI:1437506581
Name:BAUTISTA, MARY STEPHANIE GANGCUANGCO (FNP)
Entity type:Individual
Prefix:MRS
First Name:MARY STEPHANIE
Middle Name:GANGCUANGCO
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3853 W STETSON AVE
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-9674
Mailing Address - Country:US
Mailing Address - Phone:951-929-6900
Mailing Address - Fax:
Practice Address - Street 1:28062 BAXTER RD
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-1401
Practice Address - Country:US
Practice Address - Phone:956-534-6114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA676857163W00000X
CA95005578363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse