Provider Demographics
NPI:1225466063
Name:BUSTAMANTE, JESUS (PA)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 CALIFORNIA AVE STE 400B
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-7081
Mailing Address - Country:US
Mailing Address - Phone:661-459-1900
Mailing Address - Fax:661-459-1974
Practice Address - Street 1:2101 7TH ST
Practice Address - Street 2:
Practice Address - City:WASCO
Practice Address - State:CA
Practice Address - Zip Code:93280-1502
Practice Address - Country:US
Practice Address - Phone:661-758-2263
Practice Address - Fax:661-758-8132
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-14
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA635265163W00000X
363A00000X
CAPA23307363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No163W00000XNursing Service ProvidersRegistered Nurse