Basic Information
| Provider Information | |||||||||
| NPI: | 1609058924 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BUSTAMANTE | ||||||||
| FirstName: | LETICIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1809 NATIONAL AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921132113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152300 | ||||||||
| FaxNumber: | 6192690674 | ||||||||
| Practice Location | |||||||||
| Address1: | 751 WEST LEGION ROAD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | BRAWLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603518696 | ||||||||
| FaxNumber: | 7605450253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2007 | ||||||||
| LastUpdateDate: | 10/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | FNP17877 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | GR0066310 | 05 | CA | MEDICAID | FHC03830F | 05 | CA | MEDICAID |