Provider Demographics
NPI:1306838297
Name:BUSH, TRACI ANN (PT)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:ANN
Last Name:BUSH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-4104
Mailing Address - Country:US
Mailing Address - Phone:515-271-1717
Mailing Address - Fax:515-271-7185
Practice Address - Street 1:3200 GRAND AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-4104
Practice Address - Country:US
Practice Address - Phone:515-271-1717
Practice Address - Fax:515-271-7185
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00542225100000X
IA02278225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0232967Medicaid
IA650012390OtherRR MEDICARE
P29496Medicare UPIN
IAI1797Medicare ID - Type Unspecified
IA650012390OtherRR MEDICARE