Basic Information
| Provider Information | |||||||||
| NPI: | 1093193112 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSTO | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 LAKE SUMTER LNDG | ||||||||
| Address2: | |||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321622699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526748905 | ||||||||
| FaxNumber: | 3526748901 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 OLD CAMP RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8448849355 | ||||||||
| FaxNumber: | 3526748960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2015 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | APRN11020849 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 26NJ00564500 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | APRN11020849 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.