Provider Demographics
NPI:1477929461
Name:CO, MARK WESLEY BUSTILLO
Entity Type:Individual
Prefix:
First Name:MARK WESLEY
Middle Name:BUSTILLO
Last Name:CO
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 1:20151 NORDHOFF ST
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-6215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20151 NORDHOFF ST
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-6215
Practice Address - Country:US
Practice Address - Phone:818-407-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-13
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013538363LF0000X, 363L00000X
CA697369163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health