MEDICARE: JORGE LUIS BUSTILLO GONZALEZ APRN

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	363LP2300X	Primary Care Nurse Practitioner	11032235	FL
2	363LF0000X	Family Nurse Practitioner	11032235	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912750597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORGE LUIS BUSTILLO GONZALEZ APRN

Provider Business Mailing Address
First Line	:	PO BOX 4189
Second Line	:
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33442-4189
Country	:	US
Telephone Number	:	702-573-4606
Fax Number	:

Provider Business Practice Location Address
First Line	:	1395 S STATE ROAD 7 STE 420
Second Line	:
City	:	WELLINGTON
State	:	FL
Zip	:	33414-9327
Country	:	US
Telephone Number	:	561-204-4687
Fax Number	:	561-204-4694

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

Provider Enumeration Date	:	04/11/2024
Last Update Date	:	05/08/2025

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