Provider Demographics
NPI:1699289173
Name:BUSTILLOS, SAMUEL CORREA (ACNP-AG)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:CORREA
Last Name:BUSTILLOS
Suffix:
Gender:M
Credentials:ACNP-AG
Other - Prefix:
Other - First Name:SAMUEL
Other - Middle Name:CORREA
Other - Last Name:BUSTILLOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-C
Mailing Address - Street 1:1455 S VALLEY DR STE A
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3165
Mailing Address - Country:US
Mailing Address - Phone:575-526-7777
Mailing Address - Fax:575-647-1125
Practice Address - Street 1:2450 S TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5141
Practice Address - Country:US
Practice Address - Phone:575-636-7407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-20
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-03431363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care