Provider Demographics
NPI:1801894704
Name:SUSTAITA, RAUL (NP)
Entity type:Individual
Prefix:MR
First Name:RAUL
Middle Name:
Last Name:SUSTAITA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 EAST BUSINESS 83
Mailing Address - Street 2:
Mailing Address - City:DONNA
Mailing Address - State:TX
Mailing Address - Zip Code:78537-3500
Mailing Address - Country:US
Mailing Address - Phone:956-461-6666
Mailing Address - Fax:956-461-6670
Practice Address - Street 1:2010 EAST BUSINESS 83
Practice Address - Street 2:
Practice Address - City:DONNA
Practice Address - State:TX
Practice Address - Zip Code:78537-3500
Practice Address - Country:US
Practice Address - Phone:956-461-6666
Practice Address - Fax:956-461-6670
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX649350363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ28315Medicare UPIN
TX8C7874Medicare ID - Type UnspecifiedMEDICARE NUMBER