Provider Demographics
NPI:1508830423
Name:BUSBY, KENNETH V (BS / BA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:V
Last Name:BUSBY
Suffix:
Gender:M
Credentials:BS / BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 W TIETAN ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4445
Mailing Address - Country:US
Mailing Address - Phone:509-525-3720
Mailing Address - Fax:509-522-1592
Practice Address - Street 1:55 W TIETAN ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4445
Practice Address - Country:US
Practice Address - Phone:509-525-3720
Practice Address - Fax:509-525-4691
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004990363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00290212OtherRAIL ROAD MEDICARE
WA0205798OtherL&I
WA8444994Medicaid
WAG8858978Medicare PIN
WA8444994Medicaid