MEDICARE: SAMANTHA LYN BUSTILLOS NURSE PRACTITIONER

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	363LF0000X	Family Nurse Practitioner	63807	NM

General Provider Information

NPI Number	:	1689246159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA LYN BUSTILLOS NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	4085 EGYPTIAN ST
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-3573
Country	:	US
Telephone Number	:	575-636-7408
Fax Number	:

Provider Business Practice Location Address
First Line	:	4085 EGYPTIAN ST
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-3573
Country	:	US
Telephone Number	:	575-636-7408
Fax Number	:

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

Provider Enumeration Date	:	07/14/2021
Last Update Date	:	07/14/2021

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