Provider Demographics
NPI:1962831214
Name:BUSTANOBY, JEREMY FOX (DPT)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:FOX
Last Name:BUSTANOBY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3071 SAN MAMETE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141-3542
Mailing Address - Country:US
Mailing Address - Phone:757-406-9338
Mailing Address - Fax:
Practice Address - Street 1:200 E HORIZON DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-8033
Practice Address - Country:US
Practice Address - Phone:702-568-8450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2689225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist