Provider Demographics
NPI:1811751696
Name:SILVA BUSTAMANTE, DAVID ISMAEL (PTA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ISMAEL
Last Name:SILVA BUSTAMANTE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7026
Mailing Address - Country:US
Mailing Address - Phone:928-542-2283
Mailing Address - Fax:
Practice Address - Street 1:17020 TWIN LAKES AVE STE C101
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98271-4731
Practice Address - Country:US
Practice Address - Phone:360-658-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ61510432225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant