Provider Demographics
NPI:1477149904
Name:BUSTAMANTE, ROMAN
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11003 OAKTREE PARK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-4440
Mailing Address - Country:US
Mailing Address - Phone:210-727-1899
Mailing Address - Fax:
Practice Address - Street 1:11003 OAKTREE PARK
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-4440
Practice Address - Country:US
Practice Address - Phone:210-727-1899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No374U00000XNursing Service Related ProvidersHome Health Aide