Provider Demographics
NPI:1326224106
Name:BUSH, MICHELLE L (NP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:BUSH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:601 N 99TH ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4339
Mailing Address - Country:US
Mailing Address - Phone:414-874-4555
Mailing Address - Fax:414-258-1214
Practice Address - Street 1:601 N 99TH ST
Practice Address - Street 2:SUITE 107
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4339
Practice Address - Country:US
Practice Address - Phone:414-874-4555
Practice Address - Fax:414-258-1214
Is Sole Proprietor?:No
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI1554-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP09982Medicare UPIN