Provider Demographics
NPI:1710276738
Name:BUSOVA, MARINA V (PTA)
Entity Type:Individual
Prefix:MS
First Name:MARINA
Middle Name:V
Last Name:BUSOVA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 BRIARMORE DR
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-5111
Mailing Address - Country:US
Mailing Address - Phone:704-763-0688
Mailing Address - Fax:
Practice Address - Street 1:5100 SHARON RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-4768
Practice Address - Country:US
Practice Address - Phone:704-554-4818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4452225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant