Provider Demographics
NPI:1376012104
Name:RUSTIA, MARIVIC
Entity type:Individual
Prefix:
First Name:MARIVIC
Middle Name:
Last Name:RUSTIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 SW HARRISON ST APT 11D
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5387
Mailing Address - Country:US
Mailing Address - Phone:682-240-5523
Mailing Address - Fax:
Practice Address - Street 1:2222 NW LOVEJOY ST STE 411
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5102
Practice Address - Country:US
Practice Address - Phone:503-413-5598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-21
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP139794363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care