Provider Demographics
NPI:1154319820
Name:BUSHROW, KIMBERLY M (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:BUSHROW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4235 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4231
Mailing Address - Country:US
Mailing Address - Phone:419-473-3561
Mailing Address - Fax:
Practice Address - Street 1:4235 SECOR RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4231
Practice Address - Country:US
Practice Address - Phone:419-479-5795
Practice Address - Fax:419-479-5797
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001455363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP26091Medicare UPIN
OHH092010Medicare PIN