Provider Demographics
NPI:1992593420
Name:MONTALVAN-BUSTAMANTE, LUIS EDUARDO (PA-C)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:EDUARDO
Last Name:MONTALVAN-BUSTAMANTE
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 POND APPLE DR
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33332-2161
Mailing Address - Country:US
Mailing Address - Phone:954-261-2489
Mailing Address - Fax:954-261-2489
Practice Address - Street 1:950 NW 20TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33127-4622
Practice Address - Country:US
Practice Address - Phone:954-261-2489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical