Provider Demographics
NPI:1164297644
Name:BUSH, NICHOLAS (DC, MSACN)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:BUSH
Suffix:
Gender:M
Credentials:DC, MSACN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:OTEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13825-0430
Mailing Address - Country:US
Mailing Address - Phone:607-434-3206
Mailing Address - Fax:
Practice Address - Street 1:41 DIETZ STREET
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820
Practice Address - Country:US
Practice Address - Phone:607-431-9191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPENDINGGRADUATION111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor