Provider Demographics
NPI:1376254060
Name:BUSH, ALEXIS M (PA)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:M
Last Name:BUSH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6547 WENDELL ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6817
Mailing Address - Country:US
Mailing Address - Phone:616-819-9597
Mailing Address - Fax:
Practice Address - Street 1:3925 FORTUNE BLVD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-2287
Practice Address - Country:US
Practice Address - Phone:989-341-5078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-13
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012108363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program