Provider Demographics
NPI:1689246159
Name:BUSTILLOS, SAMANTHA LYN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYN
Last Name:BUSTILLOS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4085 EGYPTIAN ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3573
Mailing Address - Country:US
Mailing Address - Phone:575-636-7408
Mailing Address - Fax:
Practice Address - Street 1:4085 EGYPTIAN ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3573
Practice Address - Country:US
Practice Address - Phone:575-636-7408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM63807363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily