Provider Demographics
NPI:1497183057
Name:BUSTAMANTE, PATRICIO
Entity Type:Individual
Prefix:
First Name:PATRICIO
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 1:6735B 186TH LN
Mailing Address - Street 2:1B
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-4402
Mailing Address - Country:US
Mailing Address - Phone:347-302-5753
Mailing Address - Fax:
Practice Address - Street 1:3100 47TH AVE
Practice Address - Street 2:ALLIED MEDIX 2ND FLOOR
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-3013
Practice Address - Country:US
Practice Address - Phone:718-593-4121
Practice Address - Fax:718-268-2646
Is Sole Proprietor?:No
Enumeration Date:2013-10-17
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP90133224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant