Provider Demographics
NPI:1972275113
Name:BUSTAMANTE, ANDREA ELAINE (ND, DOM)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:ELAINE
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:ND, DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:688 CALLECITA JICARILLA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4940
Mailing Address - Country:US
Mailing Address - Phone:505-670-6726
Mailing Address - Fax:
Practice Address - Street 1:1331 MAESTAS RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6268
Practice Address - Country:US
Practice Address - Phone:575-776-7806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2021-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171100000X, 175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist