Provider Demographics
NPI:1114913332
Name:BUSH, KEVIN K (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:K
Last Name:BUSH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:151 SOUTHHALL LN
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7176
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:2709 MEREDYTH DR
Practice Address - Street 2:SUITE 340
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-0222
Practice Address - Country:US
Practice Address - Phone:229-883-1130
Practice Address - Fax:229-883-1153
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA002887363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002128AMedicaid
GA100002128AMedicaid
GA100002128AMedicaid