MEDICARE: MARIA XIMENA BUSTAMANTE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA9110780	FL

General Provider Information

NPI Number	:	1669982401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA XIMENA BUSTAMANTE PA-C

Provider Business Mailing Address
First Line	:	4061 BONITA BEACH RD STE 101
Second Line	:
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34134-4073
Country	:	US
Telephone Number	:	239-301-0105
Fax Number	:	239-288-7307

Provider Business Practice Location Address
First Line	:	4061 BONITA BEACH RD STE 101
Second Line	:
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34134-4073
Country	:	US
Telephone Number	:	239-301-0105
Fax Number	:	239-288-7307

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2017
Last Update Date	:	03/17/2018

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