Provider Demographics
NPI:1164613527
Name:BUSHMAN, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:BUSHMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 MAPLE LN STE 1
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-3610
Mailing Address - Country:US
Mailing Address - Phone:715-685-7500
Mailing Address - Fax:
Practice Address - Street 1:1615 MAPLE LN STE 1
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-3610
Practice Address - Country:US
Practice Address - Phone:715-685-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI152573-30363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1164613527Medicaid
WI1164613527Medicaid
MI1164613527Medicaid
WI040010103Medicare PIN