Provider Demographics
NPI:1982225637
Name:BUSSANICH, EVAN (LAC)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:BUSSANICH
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 MOUNT ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:ARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28704-2831
Mailing Address - Country:US
Mailing Address - Phone:828-490-1799
Mailing Address - Fax:
Practice Address - Street 1:154 MOUNT ROYAL DR
Practice Address - Street 2:
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704-2831
Practice Address - Country:US
Practice Address - Phone:828-490-1799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC588171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist