MEDICARE: MARY VIC AMOR MENDIJA BUSTILLO NP

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	20532	CA

General Provider Information

NPI Number	:	1851661276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY VIC AMOR MENDIJA BUSTILLO NP

Provider Business Mailing Address
First Line	:	1375 BLOSSOM HILL RD
Second Line	:	SUITE 49
City	:	SAN JOSE
State	:	CA
Zip	:	95118-3806
Country	:	US
Telephone Number	:	408-646-0261
Fax Number	:

Provider Business Practice Location Address
First Line	:	1375 BLOSSOM HILL RD
Second Line	:	SUITE 49
City	:	SAN JOSE
State	:	CA
Zip	:	95118-3806
Country	:	US
Telephone Number	:	408-646-0261
Fax Number	:

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

Provider Enumeration Date	:	01/02/2012
Last Update Date	:	09/09/2014

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