Provider Demographics
NPI:1376228577
Name:BUSTAMANTE, VIRGINIA ZERMENO
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:ZERMENO
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 1:1000 NORTH OAK AVENUE
Mailing Address - Street 2:MEDPEDS 1F2
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 NORTH OAK AVENUE
Practice Address - Street 2:MEDPEDS 1F2
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-3098
Practice Address - Country:US
Practice Address - Phone:715-387-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-16
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIMT228673390200000X
PAMT228673208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program