Provider Demographics
NPI:1073291696
Name:BUSHMAN, CRYSTAL LYNN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LYNN
Last Name:BUSHMAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184188 LITTLE WOLF RD
Mailing Address - Street 2:
Mailing Address - City:WITTENBERG
Mailing Address - State:WI
Mailing Address - Zip Code:54499-6052
Mailing Address - Country:US
Mailing Address - Phone:715-573-5804
Mailing Address - Fax:
Practice Address - Street 1:2720 PLAZA DR STE 1100
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4169
Practice Address - Country:US
Practice Address - Phone:715-847-2472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14163-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner