Provider Demographics
NPI:1457848566
Name:BUSIC, SANDRA LANE
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LANE
Last Name:BUSIC
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 1:201 DEER HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NC
Mailing Address - Zip Code:28675-8543
Mailing Address - Country:US
Mailing Address - Phone:336-372-2305
Mailing Address - Fax:
Practice Address - Street 1:201 DEER HAVEN RD
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NC
Practice Address - Zip Code:28675-8543
Practice Address - Country:US
Practice Address - Phone:336-372-2305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA5612225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant