Provider Demographics
NPI:1447919246
Name:BUSTAMANTE, YVETTE R (LAT)
Entity type:Individual
Prefix:
First Name:YVETTE
Middle Name:R
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 N A ST APT 5207
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-5441
Mailing Address - Country:US
Mailing Address - Phone:806-787-2733
Mailing Address - Fax:
Practice Address - Street 1:906 W ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-6198
Practice Address - Country:US
Practice Address - Phone:806-787-2733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT74352255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer