Provider Demographics
NPI:1427568807
Name:BUSSELL, KIRSTEN MACHICEK (PA -C)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:MACHICEK
Last Name:BUSSELL
Suffix:
Gender:F
Credentials:PA -C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 965
Mailing Address - Street 2:
Mailing Address - City:SHINER
Mailing Address - State:TX
Mailing Address - Zip Code:77984-0965
Mailing Address - Country:US
Mailing Address - Phone:361-594-3824
Mailing Address - Fax:361-594-3854
Practice Address - Street 1:124 E WOLTERS 2ND ST
Practice Address - Street 2:
Practice Address - City:SHINER
Practice Address - State:TX
Practice Address - Zip Code:77984
Practice Address - Country:US
Practice Address - Phone:361-594-3824
Practice Address - Fax:361-594-3854
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11615363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX742754804OtherTAX ID
TX742619228OtherTAX ID
TX083112501Medicaid