Provider Demographics
NPI:1609058924
Name:BUSTAMANTE, LETICIA
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-515-2300
Mailing Address - Fax:
Practice Address - Street 1:751 WEST LEGION ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227
Practice Address - Country:US
Practice Address - Phone:760-351-8696
Practice Address - Fax:760-545-0253
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP17877363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0066310Medicaid
CAFHC03830FMedicaid
CAW13536Medicare PIN
CAFHC03830FMedicaid