Provider Demographics
NPI:1386401453
Name:BUSTOS, YENCID I (LMT)
Entity type:Individual
Prefix:
First Name:YENCID
Middle Name:I
Last Name:BUSTOS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1867 AIRPORT WAY STE 155
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4061
Mailing Address - Country:US
Mailing Address - Phone:907-712-7966
Mailing Address - Fax:907-519-0558
Practice Address - Street 1:1867 AIRPORT WAY STE 155
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4061
Practice Address - Country:US
Practice Address - Phone:907-371-8244
Practice Address - Fax:907-519-0558
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK104025225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist