Healthcare Provider Details

I. General information

NPI: 1003069022
Provider Name (Legal Business Name): RANDI MARIE BUSTIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RANDI MARIE MARMALICH PA

II. Dates (important events)

Enumeration Date: 11/04/2008
Last Update Date: 10/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 E FOWLER AVE
TAMPA FL
33612-5416
US

IV. Provider business mailing address

PO BOX 82969
TAMPA FL
33682-2969
US

V. Phone/Fax

Practice location:
  • Phone: 813-866-0950
  • Fax: 813-866-0929
Mailing address:
  • Phone: 813-866-0930
  • Fax: 813-866-0929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9104629
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: