Provider Demographics
NPI:1417376229
Name:BUSHNELL, ANTHONY FREDERICK (PA-C)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:FREDERICK
Last Name:BUSHNELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:3340 E GOLDTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-459-7415
Mailing Address - Fax:208-453-3307
Practice Address - Street 1:315 EAST ELM
Practice Address - Street 2:STE 100
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605
Practice Address - Country:US
Practice Address - Phone:208-459-7415
Practice Address - Fax:208-453-3307
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2015-12-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDPA-1135363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant