Healthcare Provider Details

I. General information

NPI: 1811751696
Provider Name (Legal Business Name): DAVID ISMAEL SILVA BUSTAMANTE PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2024
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17020 TWIN LAKES AVE STE C101
MARYSVILLE WA
98271-4731
US

IV. Provider business mailing address

1203 BASELINE RD
BULLHEAD CITY AZ
86442-7026
US

V. Phone/Fax

Practice location:
  • Phone: 360-658-8400
  • Fax:
Mailing address:
  • Phone: 928-542-2283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number61510432
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: