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General NPI Number Information
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NPI Number | 1811751696
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Entity Type | Individual
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Provider Name | DAVID ISMAEL SILVA BUSTAMANTE PTA
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Gender | Male
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Dates
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Enumeration Date | 02/12/2024
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Last Update Date | 02/12/2024
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Provider Practice Location Address
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Address Line | 17020 TWIN LAKES AVE STE C101
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City | MARYSVILLE
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State | WA
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Zip | 98271-4731
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Country | US
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Telephone | 360-658-8400
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Fax |
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Provider Business Mailing Address
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Address Line | 1203 BASELINE RD
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City | BULLHEAD CITY
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State | AZ
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Zip | 86442-7026
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Country | US
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Telephone | 928-542-2283
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 61510432
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License Number State | AZ
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