Healthcare Provider Details

I. General information

NPI: 1225466063
Provider Name (Legal Business Name): JESUS BUSTAMANTE P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2013
Last Update Date: 07/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 7TH ST
WASCO CA
93280-1502
US

IV. Provider business mailing address

4900 CALIFORNIA AVE STE 400B
BAKERSFIELD CA
93309-7081
US

V. Phone/Fax

Practice location:
  • Phone: 661-758-2263
  • Fax: 661-758-8132
Mailing address:
  • Phone: 661-459-1900
  • Fax: 661-459-1974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number635265
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA23307
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: