Healthcare Provider Details

I. General information

NPI: 1831707876
Provider Name (Legal Business Name): MAYRA ALEJANDRA BUSTOS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 SE 8TH AVE
HILLSBORO OR
97123-4218
US

IV. Provider business mailing address

PO BOX 6149
ALOHA OR
97007-0149
US

V. Phone/Fax

Practice location:
  • Phone: 503-601-7385
  • Fax: 503-601-7311
Mailing address:
  • Phone: 503-352-8657
  • Fax: 503-352-8658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202009232NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: