Provider Demographics
NPI:1649012386
Name:BUSTAMANTE, KARISSA (PA)
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:
Last Name:BUSTAMANTE
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Gender:F
Credentials:PA
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Mailing Address - Street 1:7500 N DREAMY DRAW DR STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4668
Mailing Address - Country:US
Mailing Address - Phone:480-882-4545
Mailing Address - Fax:602-490-0499
Practice Address - Street 1:11851 N 51ST AVE STE B110
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-2823
Practice Address - Country:US
Practice Address - Phone:480-882-4545
Practice Address - Fax:623-207-7410
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-08-16
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant