Provider Demographics
NPI:1033624036
Name:RUSTIA, CORNELIO EMMANUEL BENGZON (FNP)
Entity Type:Individual
Prefix:
First Name:CORNELIO EMMANUEL
Middle Name:BENGZON
Last Name:RUSTIA
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 WILLOWSTONE CT
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92582-4247
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1324 WILLOWSTONE CT
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92582-4247
Practice Address - Country:US
Practice Address - Phone:951-665-3264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN534950163W00000X
CANP95007135363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse