Provider Demographics
NPI:1033532791
Name:BUSH, STEPHEN M (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:BUSH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHEN
Other - Middle Name:M
Other - Last Name:DIXON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:5 FIRSTVILLAGE DRIVE
Mailing Address - Street 2:PO BOX 2000
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374
Mailing Address - Country:US
Mailing Address - Phone:910-295-6831
Mailing Address - Fax:910-295-0244
Practice Address - Street 1:5 FIRSTVILLAGE DRIVE
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374
Practice Address - Country:US
Practice Address - Phone:910-295-6831
Practice Address - Fax:910-295-0244
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMB4635465363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0098694Medicaid
OH0098694Medicaid