Healthcare Provider Details

I. General information

NPI: 1265808018
Provider Name (Legal Business Name): SAMANTHA BUSSANICH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2015
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 ROUTE 72 W
MANAHAWKIN NJ
08050-2412
US

IV. Provider business mailing address

331 NEWMAN SPRINGS RD BLDG 2, STE 220
RED BANK NJ
07701-5688
US

V. Phone/Fax

Practice location:
  • Phone: 609-597-6011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00599300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA031169
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: