Provider Demographics
NPI:1346201704
Name:BUSCH, TIMOTHY (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:BUSCH
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 RANCH RD. 2222 BLDG 1
Mailing Address - Street 2:STE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730-3255
Mailing Address - Country:US
Mailing Address - Phone:512-628-0465
Mailing Address - Fax:512-233-2711
Practice Address - Street 1:5 CALLE MEDICO STE A
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4762
Practice Address - Country:US
Practice Address - Phone:505-557-6300
Practice Address - Fax:505-557-6302
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM2005-0055363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM68883722Medicaid