Provider Demographics
NPI:1730474529
Name:BUSTAMANTE, MYRA
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12755 N HIGHWAY 88
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-9323
Mailing Address - Country:US
Mailing Address - Phone:209-340-5800
Mailing Address - Fax:209-340-5804
Practice Address - Street 1:12755 N HIGHWAY 88
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-9323
Practice Address - Country:US
Practice Address - Phone:209-340-5800
Practice Address - Fax:209-340-5804
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP034207164W00000X
CAVN682197164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse