Provider Demographics
NPI:1548408511
Name:GONZAGA, INGRID KAREN BUSTO (PT)
Entity Type:Individual
Prefix:
First Name:INGRID KAREN
Middle Name:BUSTO
Last Name:GONZAGA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:INGRID KAREN
Other - Middle Name:FRANCISCO
Other - Last Name:BUSTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:731 WATERFORD DR
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-1904
Mailing Address - Country:US
Mailing Address - Phone:347-549-0957
Mailing Address - Fax:
Practice Address - Street 1:14-25 PLAZA RD
Practice Address - Street 2:SUITE 3-1
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3546
Practice Address - Country:US
Practice Address - Phone:347-549-0957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01303600225100000X
CO9294225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist