Provider Demographics
NPI:1932649878
Name:BUSTAMANTE, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
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 1:626 N WREN DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-4694
Mailing Address - Country:US
Mailing Address - Phone:785-760-0029
Mailing Address - Fax:
Practice Address - Street 1:823 SW MULVANE ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-1764
Practice Address - Country:US
Practice Address - Phone:785-234-3451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-25
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012001063163W00000X
NE77574163W00000X
KS13-117539-032163W00000X
KS514428367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse