Provider Demographics
NPI:1609945617
Name:BUSA, MARIETTA (PA)
Entity Type:Individual
Prefix:MS
First Name:MARIETTA
Middle Name:
Last Name:BUSA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 MCALPIN AVE
Mailing Address - Street 2:
Mailing Address - City:ALBERTSON
Mailing Address - State:NY
Mailing Address - Zip Code:11507-1908
Mailing Address - Country:US
Mailing Address - Phone:516-799-0210
Mailing Address - Fax:
Practice Address - Street 1:727 BROADWAY
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758
Practice Address - Country:US
Practice Address - Phone:516-799-0210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009628363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMB05779L10Medicare ID - Type Unspecified