Provider Demographics
NPI:1952598542
Name:BUSTAMANTE, GREGORY ROMO (PTA)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ROMO
Last Name:BUSTAMANTE
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Gender:M
Credentials:PTA
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Mailing Address - Street 1:2424 N WYATT DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-6115
Mailing Address - Country:US
Mailing Address - Phone:520-784-6570
Mailing Address - Fax:520-784-6574
Practice Address - Street 1:2424 N WYATT DR
Practice Address - Street 2:SUITE 130
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-6115
Practice Address - Country:US
Practice Address - Phone:520-784-6570
Practice Address - Fax:520-784-6574
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ7645A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant