Provider Demographics
NPI:1003069022
Name:BUSTIN, RANDI MARIE (PA)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:MARIE
Last Name:BUSTIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:RANDI
Other - Middle Name:MARIE
Other - Last Name:MARMALICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 82969
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33682-2969
Mailing Address - Country:US
Mailing Address - Phone:813-866-0930
Mailing Address - Fax:813-866-0929
Practice Address - Street 1:1502 E FOWLER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-5416
Practice Address - Country:US
Practice Address - Phone:813-866-0950
Practice Address - Fax:813-866-0929
Is Sole Proprietor?:No
Enumeration Date:2008-11-04
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104629363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000694400Medicaid
FLBI553ZMedicare PIN