Provider Demographics
NPI:1174287585
Name:BUSH, ISAIAH
Entity Type:Individual
Prefix:
First Name:ISAIAH
Middle Name:
Last Name:BUSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 CRAWFORD ST
Mailing Address - Street 2:
Mailing Address - City:PINE BUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12566-6711
Mailing Address - Country:US
Mailing Address - Phone:845-800-3775
Mailing Address - Fax:
Practice Address - Street 1:751 BRIGGS HWY
Practice Address - Street 2:
Practice Address - City:ELLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12428-5501
Practice Address - Country:US
Practice Address - Phone:845-647-8006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY717189163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse