Provider Demographics
NPI:1831715507
Name:BUSTOS, PEGGY DIP (FNP)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:DIP
Last Name:BUSTOS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 LAGUNA BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-7902
Mailing Address - Country:US
Mailing Address - Phone:916-478-6565
Mailing Address - Fax:
Practice Address - Street 1:8170 LAGUNA BLVD STE 101
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7902
Practice Address - Country:US
Practice Address - Phone:916-478-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014603363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily